Yorkie Rescue Colorado

Surrender Form

I certify that I am the owner of: , a Yorkshire Terrier, age:

DOB: Microchip #, or other identification: Weight:

Address: City: State: Zip Code:

Home Phone Number: Work Phone Number: E-Mail Address:

Spayed or Neutered?
Yes
No

I am voluntarily surrendering said dog to: because

Date of Last Vaccinations: Date of Last HW Test:

Date of Last HW Preventative: Name of HW Preventative Given:

Date of Last Flea Preventative: Name of Flea Preventative:

Vet Name: Vet Address:

Phone Number of Vet's Office where Vet Records can be obtained:

NOTE: Please phone your vet's office and give permission for a Yorkie Rescue Colorado member to call them and get this information.

Surrendering Owner(s):

If not owner, please explain:

Date of Surrender:

Address: Phone:

Yorkie Rescue Colorado does not buy or pay for dogs. This is a service to help place Yorkies in new homes when their present owners can no longer keep them. This service is free, however a donation to help pay for expenses is appreciated. WE DO NOT ACCEPT BITERS OR AGGRESSIVE DOGS. If we discover that this dog is a biter or is aggressive we will either return the dog to you or have him/her euthanized.

Please respond to the following, regarding the animal being surrendered, to the best of your ability - this information will help Yorkie Rescue Colorado in the placement of your surrendered dog into their new home.

Is this pet:
Housebroken? Yes No	Crate trained? Yes No
Leash trained? Yes No	Obedience trained? Yes No
Trained to do tricks? Yes No	Friendly with children? Yes No
Friendly to other animals? Yes No	Friendly with cats? Yes No

Does he/she:
Dig? Yes No	Jump fences? Yes No
Ride well in cars? Yes No	Sleep on bed or furniture? Yes No
Ever bitten another animal? Yes No	Ever bitten a person? Yes No
Chew? Yes No

Has he/she:
Ever attempted to bite another animal? Yes No	Ever attempted to bite a person? Yes No
Type of Dog Food:	Type of Treats:
Feedings Per Day: AM PM Both

Terms of Surrender

I. Terms of Release

I, the surrendering owner(s), hereby agree to irrevocably surrender to the Surrender Facilitator the following so described Yorkshire Terrier:

II. Owner's Representations and Warranties

We hereby represent and warrant to the Surrender Facilitator, successors and assignees, that we are the sole owner(s) of the above described Yorkshire Terrier and that we have unabridged authority to surrender this animal. We further assert that we are registered as the sole owner(s) of this Yorkshire Terrier with the AKC, or other pedigree registry, and require no other individual or institution's permission to affect a transfer of ownership of said pedigree registration papers. No other individual or institution has any legal or equitable interest in this animal.

III. Owner(s) Document and Information Provision

We agree to provide the Surrender Facilitator with any documents and all other available information concerning this Yorkshire Terrier that may facilitate matching this dog with the proper adoptive home. These documents may include veterinary records, vaccination records, and pedigree registrations. We also agree to provide personal knowledge of the Yorkshire Terrier's history, habits, and personality characteristics.

IV. Owner(s) Surrender of Rights

With the execution of this document, we cede all rights, title, privileges, and interests in the aforementioned Yorkshire Terrier. It is understood that this revocation extends to all future decisions concerning this dog made by the Surrender Facilitator, including medical and adoption requirements. We further stipulate that the Surrender Facilitator has sole discretion in determining whether the dog's temperament, health - especially chronic, irreversible, life-threatening, and/or painful ailments - render the dog unsuitable for adoption, requiring unforeseen actions.

V. Release and Indemnity

We agree and understand that herewith we release and hold harmless the Surrender Facilitator from any and all liability arising from the placement for adoption or any other necessary and appropriate action undertaken by the Surrender Facilitator on behalf of the aforementioned Yorkshire Terrier in accordance with and in reliance on the representations made and the authorizations given under the terms of this document.

We agree to hold harmless the Surrender Facilitator from any damages suffered, expenses incurred, including legal fees in defending or pursuing any legal action, whether for bodily injuries or death, property damage, breach of contract or otherwise, whether instituted by us or by any other individual(s) including the adoptive owners, arising out of or in consequence of the placement of this Yorkshire Terrier, in reliance on the authorizations, representations, and guarantees we have made in this agreement.

This constitutes the entire agreement between the Surrender Facilitator and us and no other terms or conditions are granted or implied.

THIS IS A LEGALLY BINDING DOCUMENT FOR THE SURRENDER OF THE AFOREMENTIONED DOG. PLEASE READ THIS CONTRACT CAREFULLY AND COMPLETELY. BE CERTAIN YOU UNDERSTAND ALL TERMS BEFORE SIGNING.

Surrendering Owner(s): Signature: Date:

Surrender Facilitator: Date:

By checking the box to the right you agree that you have read and agree to the terms of surrender

Please note any behaviors that we need to know about:

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