First Name:

Last Name:

Address:

Address 2 :

City:

State/Prov:

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Postal Code:

Telephone:

E-mail:

Occupation:

Name of Dog:

Breed:

Gender:

Date of Birth:

Where did you get the dog:

When did you get the dog:

Reason for surrender:

How did you hear about us:

Your answers to these questions help us determine the best home for your dog.

Spayed:

Neutered:

Age when spayed/neutered:

Name of Veterinarian:

Phone:

Name of Animal Hospital:

City:

State:

Zip Code:

Color(s) of Dog:

Scars, tattoos or injuries:

Is the Dog microchipped:

Medical Information

On heartworm preventative:

Current rabies vaccine:

Date of last rabies vaccine:

Current DHLPP:

Date of last DHLPP:

Current Bordetella:

Had Dog ever been treated for medical problems:

If yes, please explain:

Has Dog ever been bred:

If yes, has she had puppies:

Behaviors

House trained:

Crate Trained:

Leash Trained:

Barker:

Digger:

Dog Aggressive:

Jumps Fence:

Obedience Trained:

Knows Commands:

Which commands are known:

Where does dog sleep:

Allowed on furniture:

Free Roam of house:

How many hours is dog left alone:

Where is dog left alone:

Good with children:

Ages:

Friendly toward strangers:

Good with cats:

Good with Dogs:

Rides well in car:

Used to fenced yard:

Has tendency to run off:

Has this dog ever bitten a human being:

Has this dog ever bitten and/or injured another animal:

Type and/or brand(s) of dog food currently being fed:

How often:

Are you working with or contacted another boxer rescue:

READ, AND IF YOU AGREE, FROM THE DROPDOWN, CHOOSE AGREE IN ALL PARAGRAPHS BELOW

I / we represent that I / we are the lawful owner(s) of, and have good title to and the right and power to gift, sell, assign, transfer, convey and deliver the above-described dog; and that the above-described dog is free and clear from claims of ownership or other encumbrances of any kind or nature whatsoever by any other person or entity.

I / we fully understand that by executing this document and delivering the above-described dog to Boxers in Need of New England, Inc. that I / we hereby relinquish any and all legal and equitable rights of ownership of the above-described dog. This relinquishment is permanent and I will not be allowed to have the above-described dog returned to me or to know the above-described dog's whereabouts. I / we agree and understand that the above-described dog is now the sole and exclusive property of Boxers in Need of New England, Inc.

I / we understand that by assuming ownership, Boxers in Need of New England, Inc. reserves all rights in regards to making all decisions in regards to the above-described dog's care, placement and medical treatment. I / we further understand that Boxers in Need of New England, Inc. will evaluate the above-described dog to determine whether the above-described dog is suitable for adoption, but does not guarantee placement.

I / we understand that Boxers in Need of New England, Inc. is taking the above-described dog based on my / our statements as set forth in this agreement. I / we agree to be liable for any and all expenses, including court costs and reasonable attorney fees, incurred by Boxers in Need of New England, Inc. and its successors and assigns, which are incurred due to or in reliance on, in whole or in part, any false or misleading statement or answer made in this agreement. Furthermore, I / we hereby waive, release, discharge, and hold harmless Boxers in Need of New England, Inc. and its agents, employees, directors, representatives and other volunteers charged or chargeable with liability from any and all claims, damages, costs, expenses, loss of services, actions, and causes of actions, whether known or unknown, belonging to me, my agents and assigns, due to any action or occurrence which arises in connection with my surrender of the above-described dog to Boxers in Need of New England, Inc.

SIGNED UNDER THE PAINS AND PENALTIES OF PERJURY

Today's Date: