Release Agreement

PEKINGESE CHARITABLE FOUNDATION, INC. RESCUE PROGRAM – RELEASE AGREEMENT 

I, the undersigned, surrender and transfer my Pekingese(s) to the Representative of the Pekingese Charitable Foundation, Inc. Rescue Program and relinquish ownership of, and all responsibility for, said Pekingese(s), to the Rescue Program.  At no time will I attempt to reclaim said Pekingese(s). 

Complete the information requested, including signatures, as indicated below.  If registered, please give AKC name and number, and submit AKC registration papers and, whenever possible, the animal’s past health history, medical files and/or the name and address of the veterinarian of record. 

Pekingese:  (if more than one, please complete a form for each) 

Name                                                                      Age _____  Male                                  Female                               

Color:                                                                    

 AKC Registered Name                                                                                                                                                     

 AKC Registration Number                                                                                                                                               

 Describe any health condition for which this Pekingese is being treated:                                                                        

 List any medications that are being administered to this Pekingese:                                                                                  

 Veterinarian’s Name:                                                          Address:                                                                                  

Telephone Number:                                                                                                                                      

Present Owner: 

Name:                                                                                                                                                                                                   

 Address:                                                                                                                                                                                               

 City, State, Zip:                                                                                                                                                                                    

 Signature:                                                                                               Date:                                                                                   

 Phone Number:                                                                                  

PCF Representative: 

Name:                                                                                                                                                                                                   

 Address:                                                                                                                                                                                               

 City, State, Zip:                                                                                                                                                                                    

 Signature:                                                                                               Date:                                                                                   

 revised 05/04