Dog Owner Surrender Form

Animal Information
Name
Date of Surrender
Month
Day
Year
Age
Primary Breed
Primary Color
Gender
- Male
- Female
Altered
- Yes
- No
Bitten
- Yes
- No
If yes to bitten, please explain
Veterinarian Name
Medical History (if any)
Reason for surrender
Where did you get the dog?
When did you get the dog?
Owner Information
Owner Name
Physical Address
Street Address Address Line 2 City State ZIP Code
Email
Phone
This is to certify that on this day I have irrevocably and legally surrendered my ownership, custody, and rights to this animal(s) to the Humane Society Waterville Area. I understand that no information regarding disposition of this animal will be released to me or my representatives or assignees. I understand that my surrender of ownership, custody, and rights to this animal is final and irrevocable and the animal(s) will not be returned to me under any circumstances. I understand the Humane Society Waterville Area will attempt to find the animal(s) a suitable home or humanely euthanize the animal(s) at their sole discretion.*
- I agree
I will indemnify and hold the Humane Society Waterville Area harmless against all liability for any action taken by it in reliance on this agreement.*
- I agree
This animal HAS NOT bitten any person or other animal within the last ten (10) days. The Humane Society Waterville Area does not accept owned animals that have bitten a person or other animal.*
- I agree
My signature below states that I have read, understand, and accept the above conditions concerning the surrender of my animal(s) and also that to the best of my knowledge the information is correct.
Signature*
Date
Month
Day
Year

Dog Owner Surrender Form

Animal Information

Owner Information

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