Dog Owner Surrender Form

Animal Information

Name

Date of Surrender

MM

DD

YYYY

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

MM

DD

YYYY

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Animal Information

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