<p> Florida Yorkie Rescue 2740 SW Martin Downs Blvd., #205 Palm City, Florida 34990 772-291-8101 Surrender for Adoption Agreement</p><p>Dog’s Complete Name: Surrendering Owner(s): Address: Email: Date of Surrender: Telephone #: Cell # Cell # </p><p>Owner of Dog (Yes or No) If not owner, please explain: Reason for Surrender: FYR Representative: </p><p>Terms of Surrender I. Terms of Release We, the surrendering owner(s), hereby agree to irrevocably surrender to FYR the following so described Yorkshire Terrier or other breed dog: </p><p>Name: Sex: Age: Weight: Nicknames: Coloring: Black/Tan Reproductive Status: </p><p>Microchip # (If available): Birthdate (if known): Date of last shots: unknown Date of last heartworm test: Is dog on HW preventative? Type of food dog eats: Treats dog likes: Specific eating schedule: </p><p>List any likes/dislikes that your dog has which will help us in making him/her more comfortable in his/her new surroundings. </p><p>We forego all present and future rights, privileges, and claim to this animal.</p><p>II. Owner’s Disclosure of Temperament and Condition of Dog</p><p>We, the surrendering owner(s), hereby affirm that any and all information concerning the health and temperament of the dog, of which we are aware, is fully disclosed to FYR on this form.</p><p>Conditions/behaviors of this dog of which we are aware include: ____ Heartworms ____ Aggression toward other dogs ____ Soils floor ____ Liver Shunt ____ Aggression toward children ____ Separation Anxiety ____ Blindness _____ Aggression toward adults ____ Deafness _____ Excessive barking ____Jumps fences _____Crate trained _____Leash trained ____Obedience Trained ____Barker _____Sleeps on bed ____Digs in yard ____Skin allergies _____Dry Eye ____Ride well in car _____Enjoys being groomed ____ Other: Please list: ____ Check here if you are unaware of any of the above problems or any conditions or problems at all with this dog.</p><p>III. Owner’s Representations and Warranties We hereby represent and warrant to FYR, their agents, successors and assignees, that we are the sole owner(s) of the above described Yorkshire Terrier or other breed dog and that we have unabridged authority to surrender this animal. We further assert that we are registered as the sole owner(s) of this Yorkshire Terrier or other breed dog with the AKC, or other pedigree registry, and require no other individual or institution’s permission to affect a transfer of ownership of said pedigree registration papers. No other individual or institution has any legal or equitable interest in this animal. </p><p>IV. Owner(s) Document and Information Provision We agree to provide FYR with any documents and all other available information concerning this Yorkshire Terrier or other breed dog that may facilitate matching this dog with the proper adoptive home. These documents may include veterinary records, vaccination records, medication lists, all vet contact information and pedigree registrations. We also agree to provide personal knowledge of the Yorkshire Terrier or other breed dogs’ history, habits, and personality characteristics. Veterinarian: </p><p>Phone Number: Fax: I, ______hereby authorize representatives of FYR access to all veterinarian records from the above mentioned veterinarian. ***Signature:______</p><p>V. Owner(s) Surrender of Rights With the execution of this document, we cede all rights, title, privileges, and interests in the aforementioned Yorkshire Terrier or other breed dog. It is understood that this revocation extends to all future decisions concerning this dog made by the FYR including medical and adoption requirements. We further stipulate that the FYR has sole discretion in determining whether the dog’s temperament, health, especially chronic, irreversible, life-threatening, and/or painful ailments render the dog unsuitable for adoption, requiring unforeseen actions, including euthanasia.</p><p>VI. Release and Indemnity We agree and understand that herewith we release and hold harmless FYR from any and all liability arising from the placement for adoption or any other necessary and appropriate action undertaken by the FYR on behalf of the aforementioned Yorkshire Terrier or other breed dog in accordance with and in reliance on the representations made and the authorizations given under the terms of this document.</p><p>We agree to hold harmless FYR and its officers, members, and representatives from any damages suffered, expenses incurred, including legal fees in defending or pursuing any legal action, whether for bodily injuries or death, property damage, breach of contract or otherwise, whether instituted by us or by any other individual(s) including the adoptive owners, arising out of or in consequence of the placement of this Yorkshire Terrier or other breed dog, in reliance on the authorizations, representations, and guarantees we have made in this agreement. This constitutes the entire agreement between FYR and us and no other terms or conditions are granted or implied.</p><p>THIS IS A LEGALLY BINDING DOCUMENT FOR THE SURRENDER OF THE AFOREMENTIONED YORKSHIRE TERRIER OR OTHER BREED DOG. PLEASE READ THIS CONTRACT CAREFULLY AND COMPLETELY. BE CERTAIN YOU UNDERSTAND ALL TERMS BEFORE SIGNING.</p><p>Surrendering Owner(s)______Date ______</p><p>______Date ______</p><p>FYR Representative ______Date ______www.floridayorkierescue.com</p><p>A signed copy of this form must accompany all owner surrender rescue dogs and be forwarded to Kit DeRoche at Florida Yorkie Rescue.</p>