Michigan Basset Rescue Owner Relinquishment Form

MICHIGAN BASSET RESCUE OWNER RELINQUISHMENT DISCLOSURE STATEMENT
Please print this form and then fill out the information
On yes and no answers please indicate by circling either Y or N

Name of owner _______________________________ Phone No._________________

Address: ______________________________________________________________

Name of Dog ____________________________________________

Age/Birthdate_____________________ Color_________________

Weight______________ Photo attached? Y N

Spayed/Neutered? Y N Housebroken? Y N

Reason For Relinquishing Dog: _______________________________________________________

Good with children? Y N Explain: _____________________________________________________

Good With Other Dogs? Y N Cats? Y N Explain:________________________________________________________________

Describe This Dog's Temperament (active, laid back, etc.) _______________________________________________________________________

Any Bad Habits? (barking, chewing, digging, etc.) ________________________________________________________

Has This Dog Ever Growled, Snapped At or Bitten Anyone? Y N

If yes, explain:____________________________________________________________________________________

Is This Dog Crate Trained? Y N If Not, Where is the dog kept when you're away from home? ____________________________________________________________

Attach Copies of Veterinary Records. Immunization History, Heartworm Test-Preventive Used.

Who is your veterinarian?__________________________________ Phone Number (______) ___________________

By signing this form, I warrant I either own or have the legal right and authority to relinquish this dog. Relinquisher warrants that he has fully and completely disclosed to the rescue service all information known concerning temperament, and behavior characteristics of the animal being released. Relinquisher warrants that to the best of his knowledge, this animal has never bitten any person, nor shown aggressive behavior toward any person, nor had any serious health problems.

I understand that Michigan Basset Rescue will help me find a home for this dog by referring interested parties to me. Relinquisher remains responsible for his/her actions and agrees to hold Michigan Basset Rescue harmless from any claims arising therefrom. MICHIGAN BASSET RESCUE WILL ACT AS A REFERRAL SERVICE BUT WILL NOT TAKE IN OWNER RELINQUISHED DOGS DIRECTLY.

I am enclosing a check payable to Michigan Basset Rescue in the amount of $25.00 for this service. This fee is non-refundable.

Signed__________________________________________________________

Date____________________ Phone Number (______) ___________________

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INSTRUCTIONS: PLEASE PRINT, SIGN AND RETURN THIS FORM ALONG WITH A PHOTO TO:

MICHIGAN BASSET RESCUE
P.O. BOX 300381
WATERFORD, MICHIGAN 48330-0381
Phone 248-623-1698
Questions? Email us at mibassetrescue@att.net