RELEASE AND SURRENDER FOR ADOPTION
TERMS OF RELEASE AND SURRENDER FOR ADOPTION:
1. I/we, the undersigned, hereby IRREVOCABLY surrender to the Internet Miniature Pinscher Service (IMPS) for placement and adoption, a miniature pinscher described as follows:
CALL NAME: ________________________________ SEX: _______ COLOR: _______ AGE: _________ AKC REGISTERED NAME: ______________________________________ AKC #: _________________ HOUSEBROKEN: Y/N BARKER: Y/N GOOD WITH CHILDREN: Y/N AGES: ____________ DOG AGGRESSIVE: Y/N DIGS: Y/N GOOD WITH OTHER ANIMALS: ____________________ REASON FOR TURN IN: _______________________________________________________ SPAYED/NEUTERED ? _________________________________________________________ SHOT RECORD: ______________________________________________________________ HEARTWORM: ________________________________________________________________ ANY EXISTING HEALTH PROBLEMS ?: ___________________________________________________________________________ ___________________________________________________________________________ BREEDER CONTACTED:_________________________________________________________ OTHER COMMENTS: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
2. REPRESENTATIONS & WARRANTIES (PLEASE CIRCLE ONE) -
A. NON-OWNER
I/we hereby relinquish custody of the above mentioned Miniature Pinscher and do turn over said dog to the Internet Miniature Pinscher Service. I/we understand and agree that Internet Miniature Pinscher Service will assume responsibility for placing the dog in foster care until permanent placement is arranged. By executing this document, I/we understand that I/we are giving up forever all right, title and interest to the above-mentioned Miniature Pinscher and we further understand that all future decisions regarding the placement of this animal will be made solely by (IMPS) Rescue.
I/we understand that my/our name, address, and phone number will not be released by Internet Miniature Pinscher Rescue to anyone unless I/we specifically authorize it.
B. OWNER
We hereby represent and warrant to IMPS , their agents, successors and assigns that the undersigned are the sole owner(s) of the above described miniature pinscher. That I/we have full power and authority to surrender this animal for adoption, that I/we are the only person(s) who are listed as registered owner(s) of this animal with the AKC, the no other person or persons' signatures are required to effect a valid transfer of AKC registration papers on this animal, and that no other person or persons have any legal or equitable ownership interest in this animal.
3. DELIVERY OF REGISTRATION - I/we agree to contemporaneously with the execution of this document deliver to IMPS a properly signed transfer of the AKC registration papers for the above described miniature pinscher, omitting the name of the transferee. We hereby designate and authorize IMPS as our agent and attorney-in-fact for purposes of designation a transferee and inserting this name on the AKC registration transfer form.
4. OTHER PERTINENT INFORMATION - We also agree to provide IMPS with any documents and all other available information concerning this miniature pinscher which might assist in matching this miniature pinscher with the proper prospective adoptive home, including health and shot records, pedigree, name and address of breeder or other person from whom the dog was acquired, and information concerning this miniature pinschers "dog history," such as important life events and individual personality quirks.
5. CONSENT FOR CONTACT - We understand that IMPS may contact the breeder or previous owner of the miniature pinscher to provide additional background information, or otherwise assist in locating a suitable adoptive home and hereby give our consent to these efforts.
6. SURRENDER OF RIGHTS - By executing this document, we understand that we are giving up forever all right, title and interest to the above-mentioned miniature pinscher and we further understand that all future decisions regarding the placement of this animal will be made solely be IMPS. We also understand that if this miniature pinscher is later found to have such an unpredictable temperament as to be unsuitable for any placement, or if the animals quality of life is substantially impaired, in the opinion of a competent veterinarian, by a chronic, irreversible, painful condition, euthanasia may be considered as a final alternative to adoptive placement.
7. RELEASE AND INDEMNITY - I/we, the undersigned, hereby specifically and forever release, and hold IMPS harmless, from any and all liability arising from the placement for adoption by IMPS of the above-mentioned miniature pinscher, or for any other actions taken by IMPS in accordance with, and in reliance on, the representations we have made, and the authorizations we have provided under the terms of this document. We agree to indemnify and hold harmless IMPS for any damages suffered and expenses incurred including legal fees in defending any legal action, whether for bodily injuries or death, property damage, breach of contract, or otherwise, whether instituted by us or by any other person or persons including the adoptive owners, arising out of or in consequence of the placement of the (breed name), in reliance on the authorizations, representations and warranties we have made in this agreement.
THIS IS A LEGALLY BINDING DOCUMENT FOR THE IRREVOCABLE SURRENDER OF YOUR MINIATURE PINSCHER FOR PLACEMENT TO AN ADOPTIVE HOME. PLEASE READ CAREFULLY AND COMPLETELY BEFORE SIGNING. TAKE AS MUCH TIME AS YOU NEED TO FULLY CONSIDER THIS IMPORTANT DECISION. IF YOU HAVE ANY QUESTIONS, PLEASE CALL: 877-MINPIN1.
I have read the preceding and agree to the conditions set forth this ______ day of __________, in the year ______.
NAME OF OWNER/CUSTODIAN: _______________________________________________________ SIGNATURE OF OWNER/CUSTODIAN: __________________________________________________ NAME OF CO-OWNER/CUSTODIAN: ____________________________________________________ SIGNATURE OF CO-OWNER/CUSTODIAN: _______________________________________________ ADDRESS: __________________________________________________ CITY: ________________________________________________ STATE: _________________________ ZIP: _______________ PHONE: ___________________________________ DONATION AMOUNT: _________________________ IMPS RESCUE MEMBER: __________________________________________________
IMPS requires a hard copy of this form, complete with the signatures of owner(s) certifying the above information.
Please print & neatly complete this form.
Mail this form and all checks (made payable to IMPS) to your Regional Coordinator.