Appalachian Great Pyrenees Rescue

Appalachian Great Pyrenees Rescue

Release Surrender Contract

Description of Great Pyrenees, hereinafter referred to as “Dog”:

Registered name, if applicable:______

AKC#______Call Name:______Sex:______

Age:______Name of Sire:______

Birthdate: ______Name of Dam:______

Source of acquisition: ______

Breeders Name & any info if known: ______

______

Was the dog acquired with a sales contract? ______If yes, attach a copy of the contract

or describe terms of oral agreement:______

Is there a co-owner or does anyone have a legal interest in this dog? ______

If yes, give particulars: ______

I am willing to make a non-refundable donation in the amount of $______

to help provide care for my dog during the rescue process.

Veterinarian Name, address & phone number: ______

______

Date of last shots: Rabies:______DHLPP:______Other:______

Date of last heartworm test:______Results: ______

Date & type of last heartworm preventative:______Bordatella:______

Location & # of microchip or tattoo:______

Date & type of flea & tick preventive: ______

Has this dog ever been breed?______If spayed or neutered, please give date and Vet

info: ______

Attachments: Both parties initial space if attached:

Written acquisition contract______Medical records of dog______

Executed AKC registration papers______Other (describe)______

Please answer yes or no to the following questions:

Does dog like adults?______

Does dog like children?______

Does dog like to ride in cars?______

Does dog socialize well with cats?______

Does dog like other animals?______

Does dog have any known phobias? ______If yes please explain:______

Does dog like to swim?______

Does dog jump fences?______

Does dog chase cars?______

Does dog obsessively bark?______

Does dog urinate when scared?______

Does dog allow you to take food and or toys away?______

Does dog growl at your friends?______

Does dog like to run away?______

Does dog show any forms of aggression?____ If so please explain: ______

Does dog have any known medical problems? ______If so, please explain: ______

Does dog have any additional known bad habits?_____ If so please explain: ______

Is dog obedience trained? ______Please list known commands: ______

Is dog used to regular grooming? ______

Is dog used to being walked on a leash? ______

Has dog ever bitten a human being or other animal? ______If yes, give particulars: ______

Where was dogs primary residence? Indoors:_____ Outdoors:____ Other:_____

What is the reason you are surrendering your dog?

I/we hereby state that I/we are the sole owner(s) of the above described dog and that there are no other parties that may have a legal interest in this dog. I/we hereby surrender all of my/our interests and ownership rights, including any American Kennel Club registration papers, for this dog to Appalachian Great Pyrenees Rescue (AGPR), and hereby relinquish all claims to this dog. I/we understand that the surrender and release of my/our ownership in this dog is irrevocable and immediate. I/we understand and agree that AGPR has not made any explicit implied promises regarding future placement or disposition of this dog. I/we state and affirm that to the best of my/our knowledge, the information I/we provided above is true, correct, and complete. I/we understand that if I/we have not made full and complete disclosure about any information asked above, I/we agree to hold AGPR harmless and indemnify AGPR for any damages resulting from AGPR relying upon the above disclosed information. I/we understand and agree that I/we are surrendering this dog to AGPR of my/our own free will and that such surrender and or release does not constitute a sale I/we understand and agree that I/we will receive no money or other compensation as a result of surrendering/releasing this dog but that I/we have received a benefit from this surrender in that I/we care no longer for this dog.

Such surrender and or release is executed this ______day of______20_____

Signature of owner:______

Print name of owner:______

Address:______

Phone: Home______Work______

Email:______

Signature of co-owner:______

Print name of co-owner:______

Address:______

Phone: Home:______Work______

Email______

Signature of AGPR representative:______

Victoria Marshman, Director

Phone: (804) 795-7847or ______