RESCUE PROGRAM
I, ____________________________________________________, do hereby surrender to the American Maltese Association, Rescue Program (hereafter called Maltese Rescue) this Maltese named:
_______________________________________________________________________________.
I certify that I am the sole owner of this dog, free and clear of all other interests. I also certify that this dog is not possessed of any dangerous or vicious propensities. The information I have provided about the history of this dog is true and complete to the best of my knowledge.
I authorize Maltese Rescue to place this dog into a new home at their discretion and to the best of their ability.
I irrevocably relinquish unto the Maltese Rescue, all rights, title and interest in and to the dog surrendered as of this date.
I hereby forever release, discharge, and agree to hold harmless and indemnify Maltese Rescue, its Board of Directors, its officers, members and agents from all claims, demands, actions, causes of action, and liability of any kind whatsoever arising as a result of or in connection with the surrender and subsequent adoption or other disposition of this surrendered dog from this day forward.
Read, understood and agreed,
Print name: ________________________________________________________
Address: __________________________________________________________
City, State, Zip: ____________________________________________________
Home phone: ______________________________________________________
Signature: _________________________________________________________
Print name: ________________________________________________________
Address: __________________________________________________________
City, State, Zip: ____________________________________________________
Home phone: ______________________________________________________
Home fax: _________________________________________________________
Date Surrendered: ___________________________________________________