P. O. BOX 81821, AUSTIN, TX 78708-1821
PHONE: 512-259-5810
TELEPHONE REFERRAL & RELEASE AGREEMENT
Case Number:_______________ Release Date:_______________
OWNER INFORMATION
Name :
____________________________________________________________________________________
Address:
____________________________________________________________________________________
City/State/Zip:
____________________________________________________________________________________
Home Phone:
____________________________________________________________________________________
Work Phone:
_____________________________________________________________________________________
Fax:
_____________________________________________________________________________________
Email:
_____________________________________________________________________________________
Why is this dog up for adoption?
________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
DOG INFORMATION
Registered Name: ____________________________
Call Name: _______________________________
AKC Number: _______________________________
Microchip/Tattoo# _________________________
Neutered/Spayed: _____________________________
Sex : Male
Female
Color: Black
Yellow
Chocolate
Markings: ________________________________
Age/Date of Birth:_________________________________
QUESTIONS
Is the dog good with children? | Yes | No | Unknown |
Is the dog good with other dogs? | Yes | No | Unknown |
Has the dog has basic obedience training? | Yes | No | Unknown |
Has the dog kill/chased other animals? | Yes | No | Unknown |
Has the dog ever bitten a person? | Yes | No | Unknown |
Was the bite reported to animal control? | Yes | No | Unknown |
Was the dog quarantined? | Yes | No | Unknown |
Does the dog growl when you take away its food or toys? | Yes | No | Unknown |
Is the dog house-trained? | Yes | No | Unknown |
How long have you owned the dog? _____________________________________________________________ |
From where did you get the dog? | Breeder | Pet Store | Shelter | Other |
Have you contacted the breeder? | Yes | No |
What dog food is the dog eating? ________________________________________________________________ |
How much/often is the dog fed? ________________________________________________________________ |
What is the brand of monthly heartworm prevention, and when was the last date it was given? ____________________________________________________________________________________ |
Circle any bad habits of the dog: | Chewing | Barking | Jumping | Digging |
Other: Please explain: | _____________________________________________________________________ |
Name, address, and phone # of Vet:
____________________________________________________________
____________________________________________________________
____________________________________________________________
I certify that I am the owner of the described dog, and as such do release Heart of
Texas Lab Rescue, Inc. of any
responsibility in placing this dog in another home. Heart of Texas Lab Rescue, Inc.
has NOT observed and evaluated
this dog and is only being involved for possible telephone referrals. I also
certify that this dog is not possessed of
any dangerous or vicious propensities, and that I have not willfully concealed information
about this dog that might
indicate such propensities. The information I have provided about this dog is true
and complete. I hereby FOREVER
release, discharge, and agree to hold harmless and indemnify Heart of Texas Lab Rescue,
Inc., its board of directors,
officers, members, and agents from all claims, demands, actions, causes of action, or
liability of any kind whatsoever
arising as a result of or in connection with the adoption of the above described dog.
Read, understood and agreed:
__________________________________________________________________
Signature
_________________________________________________________________________________
Date:
_________________________________________________________________________________
Representative of Heart of Texas Lab Rescue, Inc.
____________________________________________________
Signature
_________________________________________________________________________________
Date:
_________________________________________________________________________________
Please include ALL of the following to the address above:
1. This form, signed and dated
2. Written proof from a vet that all of the following
was done:
a.
Current heartworm test showing it is negative of heartworms
b.
Current on shots
c.
Spayed/Neutered
3. A biographical paragraph about the dog so
prospective adopters can get to know the dog
4. A picture of the dog so it can be identified as a pure-bred
Labrador Retriever. Hard copies of pictures will NOT
be returned. (If you
prefer to email this picture, please send it to wannalab5656@yahoo.com
along with name of the
dog, owner/foster's
name AND indicate that you are mailing the required Telephone Referral paperwork to our
PO Box address)