First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County*

Email*

Home Phone

Work Phone
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Cell Phone*

Alt Email

SELECT ANIMAL NAME FROM DROP-DOWN IF APPEARS BELOW: only if name is there.
Choose an animal: Briggs Brody Foster - Apply to be a Foster Home Newton

ENTER --} NAME OF ANIMAL BEING SURRENDERED (HEREIN REFERRED TO AS ANIMAL) {--- (REQUIRED)*

WHERE DID YOU GET ANIMAL? ----} PLEASE PROVIDE THE NAME OF: PERSON, RESCUE, SHELTER, BREEDER, OR DESCRIBE OTHER: {--- (REQUIRED)*

PLEASE ENTER THE DATE YOU FROM WHEN YOU ACQUIRED ANIMAL: MM/DD/YYYY {--- (REQUIRED)*

ENTER ---} SPECIES OF ANIMAL {--- (REQUIRED)*

ENTER ---} BREED OF ANIMAL {-- (REQUIRED)*

ENTER ---} AGE OF ANIMAL OR DATE OF BIRTH {--- (REQUIRED)*

ENTER ---} WEIGHT OF ANIMAL{-- (REQUIRED)*

ENTER SEX OF ANIMAL{-- (REQUIRED)*

HAS ANIMAL BEEN SPAYED / NEUTERED? {-- (REQUIRED) YES - NO- OR N/A*

ENTER DATE ANIMAL LAST RECEIVED RABIES VACCINATION {--- (REQUIRED) If not applicable enter NA *

ENTER DATE ANIMAL LAST RECEIVED DISTEMPER / PARVO / DHPP VACCINATION? {--- (REQUIRED) If not applicable enter NA*

ENTER DATE ANIMAL WAS TESTED FOR HEART-WORMS? {-- (REQUIRED) If not applicable enter NA if unknown enter UNKNOWN*

ENTER THE NAME OF HEART-WORM PREVENTATIVE BEING USED AND }} DATE LAST ADMINISTERED? {-- (REQUIRED) If not applicable enter NA if unknown enter UNKNOWN*

ENTER THE DATE ANIMAL LAST RECEIVED A LYME TEST/VACCINATION? {-- (REQUIRED) If not applicable enter NA if unknown enter UNKNOWN*

ENTER DATE ANIMAL LAST RECEIVED BORDETELLA VACCINE? {--- (REQUIRED) If not applicable enter NA if unknown enter UNKNOWN*

HAS ANIMAL BEEN MICRO-CHIPPED? {--- (REQUIRED) ANSWER YES - NO - N/A*

IF YOU ANSWERED YES TO MICRO-CHIPPED--- ENTER THE CHIP MANUFACTURER NAME {--- (REQUIRED) If not applicable enter NA If unknown enter UNKNOWN

IF YOU ANSWERED YES TO MICRO-CHIPPED--- ENTER MICRO-CHIP IDENTIFICATION NUMBER? {--- (REQUIRED) If not applicable enter NA If unknown enter UNKNOWN

ENTER MANUFACTURER NAME OF FLEA / TICK PREVENTATIVE BEING USED? {--- (REQUIRED) If not Applicable enter NA If unknown enter UNKNOWN*

ENTER DATE LAST FLEA / TICK PREVENTATIVE WAS GIVEN? {--- (REQUIRED) If not applicable enter NA if unknown enter UNKNOWN*

ENTER HERE THE NAME OF THE FOOD ANIMAL HAS BEEN EATING. {---} ENTER BELOW HOW OFTEN ANIMAL EATS. {---} ENTER BELOW HOW MUCH FOOD ANIMAL IS EATING. {--- (REQUIRED) if unknown enter UNKNOWN.*

HAS ANIMAL EVER BITTEN A HUMAN {--- (REQUIRED) YES OR NO*

IF ANIMAL HAS BITTEN ANY HUMANS, DID HUMANS SEEK MEDICAL ATTENTION? {--- (REQUIRED) YES - NO - N/A*

IF ANIMAL HAS EVER BITTEN A HUMAN WAS A REPORT TAKEN BY ANIMAL CONTROL? {--- (REQUIRED) YES - NO - N/A*

IF YOU ANSWERED YES TO ANY OF THE THREE PREVIOUS QUESTIONS PROVIDE, NAME, ADDRESS, CITY, ST, ZIP, AND PHONE, OF HUMAN BITTEN. DESCRIBE INCIDENT FILLY AND IN DETAIL. {---- (REQUIRED) If there was no incident enter NONE *

IF A REPORT WAS GENERATED BY ANIMAL CONTROL PROVIDE A FULL AND COMPLETE COPY OF SAID REPORT. ENTER IN SPACE THE NAME OF AGENCY THAT TOOK THE REPORT CONTACT INFORMATION {--- (REQUIRED) If there was no incident type NONE*

HAS ANIMAL BITTEN MORE THAN ONCE. YES OR NO {--- (REQUIRED) You must answer YES or NO*

OWNER represents that the information provided to HALS regarding the animal’s health and history with humans and other animals is true and accurate. YES or NO DO YOU AGREE? ---} Please ANSWER YES or NO {--- (REQUIRED) *

(OWNER) hereby transfers ownership of the Animal, herein described, to Home At Last Sanctuary, Inc., (HALS) a 501(3) c Public Charity, Mailing address 11140 Rockville #100-338 MD 20852 (301) 983-0614. OWNER hereby represents, warrants, and certifies that he/she has sole ownership of this Animal and authority to enter into this agreement, and that OWNER has no obligation under any other agreement, written or verbal, to return this Animal to any other person, shelter, rescue group, or entity. OWNER shall indemnify and hold HALS harmless against any claim by a third party relating to Owner's ownership of the Animal and/or authority to transfer ownership to HALS. ----} PLEASE ENTER THE LEGAL NAME OF THE CURRENT OWNER OF ANIMAL. IF OWNER IS DECEASED ENTER "DECEASED" AFTER THE OWNER'S NAME FOLLOWED BY THE DATE OWNER PASSED {--- (REQUIRED)*

ENTER OWNER CURRENT OR MOST RECENT LEGAL ADDRESS {--- (REQUIRED)*

ENTER HERE ---} OWNER CITY {--- (REQUIRED)*

ENTER ---} OWNER STATE {--- (REQUIRED)*

ENTER --} OWNER ZIP CODE {--- (REQUIRED)*

ENTER --} OWNER HOME PHONE {--- (REQUIRED) YOU MUST ENTER ANY PHONE NUMBER*

ENTER OWNER CELL PHONE {--- (REQUIRED) YOU MUST ENTER ANY PHONE NUMBER*

OWNER acknowledges and agrees that, IF ANIMAL IS ACCEPTED into HALS Owner-Surrender program, he/she is transferring full LEGAL TITLE AND OWNERSHIP of the Animal to HALS and that all decisions as to the further placement of the Animal will be made by HALS in its sole discretion. OWNER hereby promises not to assert any claim against HALS for return of the Animal, and agrees that it should pay all legal costs incurred by HALS in defending such a claim. DO YOU AGREE YES or NO {--- (REQUIRED)*

IF ANIMAL IS CURRENTLY LIVING WITH SOMEONE OTHER THAN OWNER PROVIDE THE ---} NAME OF CURRENT CAREGIVER {---

ENTER CAREGIVER'S ADDRESS

ENTER CAREGIVER'S CITY

ENTER CAREGIVER'S STATE

ENTER CAREGIVER'S ZIP CODE

ENTER CAREGIVER'S CELL PHONE OR OTHER PHONE NUMBER

ENTER THE MOST RECENT DATE ANIMAL WAS SEEN BY A VETERINARIAN? {--- (REQUIRED) IF Unknown type UNKNOWN*

ENTER NAME OF VETERINARIAN THAT LAST SAW ANIMAL? {--- (REQUIRED) If unknown enter UNKNOWN*

PROVIDE THE PHONE NUMBER OF YOUR VETERINARIAN (--- (REQUIRED)*

ENTER ADDRESS, CITY, STATE AND ZIP CODE OF VETERINARIAN {--- (REQUIRED)*

HEALTH INFORMATION: DOES ANIMAL HAVE ANY CURRENT MEDICAL ISSUES OR CONDITIONS? IF YES PROVIDE DETAILS. {--- (REQUIRED) If not applicable enter NA If none enter NONE*

DESCRIBE YOUR ANIMAL AS YOU WOULD ON A DATING SITE. {--- (REQUIRED) *

HELP DESCRIBE HOW YOUR ANIMAL INTERACTS WITH OTHER HUMANS. {---} CHECK ALL THAT APPLY.

HELP DESCRIBE HOW YOUR ANIMAL INTERACTS WITH OTHER DOGS. {---} CHECK ALL THAT APPLY.

DESCRIBE HOW YOUR ANIMAL INTERACTS WITH CATS {---} CHECK ALL THAT APPLY.

DESCRIBE HOW YOUR ANIMAL HUNTING INSTINCT {---} CHECK ALL THAT APPLY.

DESCRIBE HOW YOUR ANIMAL ACTS IN GENERAL IN THE FOLLOWING {---} CHECK ALL THAT APPLY.

DESCRIBE YOUR ANIMAL'S TRAINING {---} CHECK ALL THAT APPLY.

If HALS places the Animal with an adopter, that adopter’s information will be confidential and not available for the OWNER executing this agreement, unless the new adopter consents to disclosure of his/her identity. You are free to contact your volunteer with questions concerning how the Animal is adjusting to his/her new home. (THESE FIELDS WILL BE FILLED IN WHEN PRINTED) Volunteer Name ______________________ Phone (_____) ______________ {---} OWNER will not contact adoptive family for any reason. OWNER is to contact HALS ONLY with any questions about Animal. Making contact with new family could be viewed by the new adopter as an invasion of privacy and detrimental to the reputation of HALS and its ability to carry out its mission of rescuing Animals and placing them in new homes. OWNER will pay liquidated damages of $2,000.00 to HALS in the event it breaches this provision, and will be liable for all legal fees associated with enforcing any part of this agreement. DO YOU AGREE YES or NO {--- (REQUIRED) ANSWER YES - NO*

HALS is a non-profit and funded by donations. Volunteers receive no compensation. Your donation to HALS will be used to defray veterinary and other expenses for animals taken into rescue. All Animals must be spayed/neutered, up to date on vaccines and parasite free before going to a new home. HALS strongly advises having your Animal's medical care current and all vaccinations up-to-date. Inability to update your animals care will not disqualify your Animal from our Owner Surrender program. OWNER is asked to donate (THESE FIELDS WILL BE FILLED IN WHEN PRINTED) $______ (cash/check_____) ($500.00 recommended donation). A donation is NOT mandatory. Smaller amounts are accepted. Home At Last Sanctuary, Inc. is a 501(c) 3 non-profit. If a check is used; OWNER hereby represents that this check has sufficient funds to cover the amount of the donation and that if said check does not have sufficient funds, OWNER will be liable for the amount of the donation as well as any bank fees or other collection costs incurred by HALS. ----} ENTER DOLLAR AMOUNT OF DONATION BELOW -- {--- (REQUIRED) IF you will make NO donation at this time enter $0.00 Below {---. $$ *

This document authorizes the release of any and all records or information in the possession of anyone that has provided care for Animal described herein including but not limited; veterinarians, groomers, trainers, behaviorists, or kennels to Home At Last Sanctuary, Inc. 11140 Rockville Pike, Ste#100-338, Rockville MD 20852 (301) 983-0614 OWNER, signed below, acknowledges surrender OF LEGAL TITLE AND OWNERSHIP of Animal. ---} TYPE YOUR FULL NAME AND TODAY'S DATE BELOW TO ATTEST YOU HAVE ANSWERED ALL QUESTIONS HONESTLY, COMPLETELY AND TO THE BEST OF YOUR KNOWLEDGE . }{-- (REQUIRED) *

Owner agrees and understands this document does not guarantee Animal will be accepted into our Owner Surrender Program. A full review of all information and verification is necessary along with a behavioral assessment by HALS. Proof of ownership is required for HALS to take possession of Animal. DO YOU AGREE?----} YES OR NO {--- (REQUIRED)*