HEART OF TEXAS LAB RESCUE, INC.

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:     ____________________________________________________________
                                                           ____________________________________________________________
                                                            ____________________________________________________________

PLEASE READ CAREFULLY, SIGN AND DATE:

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)

ALL ITEMS MUST BE RECEIVED FOR THE DOG TO BE
CONSIDERED FOR TELEPHONE REFERRAL