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DOG SURRENDER AGREEMENT

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					                 DOG SURRENDER AGREEMENT
It is preferable that this form is completed digitally, with the exception of page five, which should be
handwritten and signed. This is to aid data entry for SA Dog Rescue record keeping. Please inset text
in the box below each heading. Please provide as much detail as possible. The boxes marked with an
asterisk * must be filled in.

Dog(s) name      Breed     Gender     Birth date*                   Colour      Distinguishing features
*                            M/F      (estimate if not known)
                                              dd/mm/yy



Surrendered from *                  Council      Microchip        Is the dog de-   Tattoo (details)
(surname and given name)            Reg No.      Number           sexed?* Y/N



Reason for Surrender                Did you contact the      Where was the dog obtained?
                                    breeder? (y/N)


INSERT PICTURE OF SURRENDERED DOG HERE




HEALTH and immunisation

                                         Date immunisation due* (dd/mm/yy)
Vet record        C3          C5            Kennel       Flea        Heartworm Intestinal
available Y/N                               cough        treatment             worms




SADR Surrender Agreement July 2010
What food is fed regularly to the dog

Other comments



BEHAVIOUR

Housetrained Y/N

Crate trained Y/N

Obedience training
None/basic/intermediate/advanced

Biting Y/N

Destructive behaviour (type, eg chewing,
scratching, digging, etc)
Escapes Y/N

Is the dog used to other dogs, cats, other animals
children (All that apply)
Behaviour issues i.e. fear, anxiety, separation
anxiety food protection
Any other information that may help us place
the dog in a new home


OFFICE USE ONLY

SA DR Shelter number

Date dog received

SADR Representative


Dog placed shelter

Dog placed Foster carer




SADR Surrender Agreement July 2010
RELEASE /SURRENDER


I/We state that I/We are the sole owners of the above described dog and that no other party have a
legal or financial interest in this dog


I/we state that all the information given in this document is true to the best of my/our knowledge. In
the event that misleading information is provided on this form, SA Dog Rescue is entitled to recover
costs from the signatory that relate to loss arising from any false declaration or deliberate omission.


I/We relinquish all rights, interest and ownership of the above dog to SA Dog Rescue and hereby
relinquish all claims to said dog.


I/We understand that this surrender is irrevocable and ownership of said dog is relinquished to SA
Dog Rescue


I/We further understand and agree that I/We will receive no money or any other compensation as a
result of this surrender


Any donation made to SA Dog Rescue does not constitute a sale and this donation will be used to
benefit future SA Dog Rescue activities relating to dog rescue




This surrender is made on this day____________ of___________________ year _____________



Surrendering owners name (print)___________________________ sign______________________



Address_________________________________________________________________________



Phone numbers___________________________________________________________________



Witnessed by ____________________________________________________________________




SADR Surrender Agreement July 2010

				
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posted:7/21/2011
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