*a 501(c) (3) nonprofit corporation



I__________________________________________, on this date ________________ do hereby unconditionally surrender ownership of the following dog:


Dog's Name ______________________ RAGofAZ Intake # ____________


Gender ________ Neutered/Spayed (circle one, if applicable)


Dog's Age ______ Birth date if known ____________


to ___________________________________________, a representative of Rescue A Golden of Arizona.


I represent and warrant that I am the sole owner of the Golden Retriever described above, that I have full power and authority to surrender this animal for adoption, and that no other person has any legal or equitable ownership interest in the Golden Retriever released. By signing this document, I give complete ownership of the above mentioned dog to Rescue A Golden of Arizona. I understand that I am irrevocably relinquishing all rights, title and possession to the above mentioned dog and that the dog now belongs solely to Rescue A Golden of Arizona, who will decide the best course of action to take regarding this dog. I understand that I will take no action of any kind against the volunteers of Rescue A Golden of Arizonafor any reason arising out of this release. I certify that, to the best of my knowledge, this dog has no history of biting or showing aggressive behavior of any kind.


I hereby authorize the release of all medical records regarding the above-mentioned dog to Rescue A Golden of Arizona upon request. If the dog has a registered microchip, I authorize the microchip company to transfer the registration to Rescue A Golden of Arizona.


Vet Practice & Doctor’s name Address


City State Zip code Phone #



Signed _________________________________________________ Date _________________


Signed _________________________________________________ Date _________________


_______________________________________________________ Date _________________

Signature of Representative of Rescue A Golden of Arizona


Rev.8/ 2010