AWPGA Rescue Surrender Intake Form Todays Date * MM DD YYYY Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Registered Name (If applicable) Call Name AKC Registration Number Sex Male Female Date of Birth (If known) MM DD YYYY Microchip/Tattoo # Height and Weight Dog Breeder (If Known) Spayed or Neutered Yes No Check all that Apply Travels well in car Housebroken Crate trained Temperament Calm Medium energy High energy Health Problems Yes No Hunting Experience Yes No Behavioral Problems Yes No When outside, dog is Contained by fence Invisible fence Leash walked Runs loose Other Good With Children Other dogs Cats Other pets Other Any History of Aggression Yes No Exercise needed (minutes/day) Commands known and response Other information about the dog (likes/dislikes) Reason for placing the dog with AWPGA Rescue Any other info Surrender Agreement I/we am/are the true, rightful and legal owners of the dog identified above or have full legal authority to act on behalf of the owners of such dog. The surrender contemplated hereby does not infringe or violate the rights of any other person. By signing below, I/we am/are hereby surrendering such dog, and conveying full and complete right, title and interest in and to the dog, to AWPGA Rescue. AWPGA Rescue will assume legal ownership of the dog until the dog is adopted by a new owner. I/We understand and agree that by surrendering and relinquishing ownership of the dog, I/we will not be able to determine its final placement. I/we further understand and agree that if I/we seek to reclaim the dog, I/we will have to go through the AWPGA Rescue‘s regular adoption procedures, including payment of adoption fees. I/we also understand and agree that if I/we breach any term of this agreement, including by misrepresenting our ownership of the dog or by failing to deliver custody of the dog to AWPGA Rescue, its representatives or authorized agents, then I/we shall be liable for, and shall promptly pay to the AWPGA Rescue, liquidated damages in the amount of $130. I/we agree that such amount is fair and reasonable. I/we understand that I/we remain responsible for the costs of care and upkeep of the dog while it remains in my/our custody. * Confirm I agree that submitting this form shall be taken as a legal substitute for my signature. * Confirm Name * First Name Last Name Thank you!
