Surrender Agreement

I, ___________________, an adult, do hereby voluntarily and irrevocably give, donate, surrender and release to Cocker Spaniel Adoption Center, Inc., hereinafter referred to as CSAC, the following animal(s), hereinafter referred to collectively as "Animal(s)":

Animal(s)' Name(s): _____________________________

Male _______ Female _______ (If multiples, list numbers)

Color(s):__________________________________

Age(s):___________________________________

I represent and warrant that I am the lawful owner of the Animal(s), and I have full power and authority to surrender the Animal(s) to CSAC. No other person has any legal or equitable ownership interest in the Animal(s).

I have disclosed to CSAC all material information regarding the medical and behavioral history of the Animal(s). I willfully surrender all medical records and information pertaining to the Animal(s). CSAC has my permission to contact my veterinarian for any necessary information pertaining to my Animal(s), and I hereby consent to the release of any and all medical information by any medical provider.

Veterinarian's name: ______________________________

Address: _______________________________________

______________________________________________

Phone Number: ___________________________________

I further acknowledge that I am releasing the Animal(s) completely voluntarily and that no representations, considerations or promises of any kind have been made to me by CSAC or any of its representatives.

List any particular concerns or things CSAC should know about the Animal(s) -- good and not so good:

I understand that by releasing the Animal(s) to CSAC, I relinquish all ownership or other interest in the Animal(s). I will not seek further information about the Animal(s) and will not press CSAC for details. My contact with the Animal(s) terminates at the time of surrender. CSAC is under no obligation whatsoever to follow up with information about the Animal(s).

I hereby release and forever discharge CSAC from any and all rights, claims, obligations, liabilities, and causes of action whatsoever arising out of or relating to the ownership, possession, or disposition of the Animal(s), and I agree to indemnify and hold harmless CSAC from and against any and all such rights, claims, obligations, liabilities, and causes of action which may be asserted by third parties.

This is a legally binding document for the irrevocable surrender of your Animal(s) to CSAC.

I have fully read and understand this Surrender Agreement. I accept and agree to abide by its terms.

DATE:________________________________________

OWNER'S SIGNATURE: ___________________________

OWNER'S NAME: ________________________________

OWNER'S ADDRESS: _____________________________

_____________________________________________

OWNER'S PHONE NUMBER(S): ______________________

_____________________________________________

OWNER'S E-MAIL: _______________________________

WITNESS:______________________________________

CSAC AGENT TAKING CUSTODY:_______________________