Release of Ownership Agreement - Owner Surrender

After completion and submission of this agreement, you should receive a copy via e-mail shortly. Please be sure to enter a valid e-mail address before submitting the agreement.

PART I

Instructions: Part I of this Release of Ownership Agreement (this "Agreement") is designed to provide Col. Potter Cairn Rescue Network with adequate information on the Terrier or Terrier mix (now referred to as the "Dog") that you are releasing to Cairn Rescue.

General Information

AKC Registered Name of the Dog:

Pet name and nick names: *

Is the dog a purebred Terrier or a Terrier-Mix? *

Pure
MIx

If this is a mix, what is the mix?

Gender

Male
Female

Age of Dog:

Date of Birth (if known):

Please supply us with any prior known history of this Dog if you have not had the dog since it was a young dog:

Where did you obtain this Dog?

If purchased from a breeder or adopted through a rescue organization, please provide the following information:

Name of Breeder or Rescue Org:

Address:

City

State/Prov

Zip Code

Phone

Breeder Information

If you obtained this Dog from a breeder, please answer the following questions:

Was a contract signed with the breeder at the time of purchase?

Yes
No

If a contract was signed, will you be able to provide a copy to Col. Potter Cairn Rescue?

Yes
No

Do you have AKC Registration papers for this Dog?

Yes
No

If yes, will you give Col. Potte Cairn Rescue signed AKC Registration papers transferring ownership?

Yes
No

Identification

Color of Dog:

How much does the Dog weigh?

Is the Dog overweight or underweight?

Overweight
Underweight
Just right

Is the Dog tattooed?

Yes
No

If the Dog is tattooed, please provide the following information, and have any documents available:

Location of Tattoo:

Tattoo Number:

Is the Dog microchipped?

Yes
No

If the Dog is microchipped, please provide the following information, and have any documents available:

Microchip Number

Registry/Microchip Company:

Registry / Microchip Company Phone Number:

Does the Dog have any scars or distinguishing features?

Yes
No

If so, please describe:

PART II

Terms of Release and Surrender

This is a legally binding document for the irrevocable surrender of your Dog to Col. Potter Cairn Rescue. Please read it carefully and completely before signing it. Take as much time as you need to fully consider this important decision. If you have any questions, please contact us.

Your signature will be required prior to surrendering your Cairn. You must also provide proof of being of legal age in your state to sign contracts. Photographic identification with your current address will be required prior to surrender. For good and valuable consideration, the receipt and sufficiency of which I hereby confirm and acknowledge, I, being over the age of 18 years and of sound mind, hereby irrevocably and unconditionally surrender to Col. Potter Cairn Rescue for placement and adoption, the Dog described in Part I of this Agreement.

I understand that by executing this document, I am giving up forever all right, title and interest to such Dog, and that all future decisions regarding the placement of this animal will be made solely by Col. PotterCairn Rescue. I also understand that if this Dog is later found to have such an unpredictable temperament as to be unsuitable for any placement, or if the Dog's quality of life is substantially impaired, in the opinion of a competent veterinarian, by a chronic, irreversible and/or painful condition, Col. Potter Cairn Rescue may consider euthanasia as a final alternative to adoptive placement.

I represent and warrant that the information provided on Parts I and II of this Agreement is the truth to the best of my knowledge and belief and agree (jointly and severally if this Agreement is executed by more than one owner) to hold Col. PotterCairn Rescue, its officers, directors, representatives and volunteers, and any other group or organization that may place this Dog in reliance on the information provided in this Agreement, harmless from any loss or injury resulting from any false information or misrepresentations that I may have submitted or made in this Agreement.

I further represent and warrant to Col. Potter Cairn Rescue, its officers, directors, representatives, and volunteers, that I (and if applicable, any other signatories to this Agreement) (i) am/are the sole owner(s) of this Dog (ii) have full power and authority to surrender this animal for adoption (iii) am/are the only person(s) listed as the registered owner(s) of this animal with the AKC (if said Dog is registered).

If the Cairn is AKC registered and I have indicated in Part I that I am able to provide AKC Registration Papers for the Dog to Col. Potter Cairn Rescue, I agree to deliver to Col. Potter Cairn Rescue a properly signed transfer of such AK registration papers, omitting the name of the transferee, and hereby designate and authorize Col. Potter Cairn Rescue as my agent and attorney]

Please make sure the application is complete before pressing the "Submit" button below. Incomplete applications may be rejected or delayed.