Welcome to Fila 911

I am the legal owner of this dog and I surrender all claim of ownership of this dog to Fila 911 Rescue and Rehab
(Fila 911) without recourse. I understand that all possible attempts will be made to place the dog into a loving
home as a pet where the dog will be welled cared for. I also understand that the Fila 911 committee will decide
what action will be taken with the dog.

Contact Information

First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
-

Email*

Home Phone

Work Phone
x

Cell Phone*

Alt Email*

Text/Pager Email

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Name of Dog:*

Breed of Dog:*

Age/Date of Birth:*

Is the dog:*

Current Dog Weight:*

Color of Dog*

Eye Color*

The dog described is licensed this year and I am surrendering its license and rabies tag.

Yes

The dog described herein is micro-chipped:

Yes

If dog is microchipped, the agency and microchip # is:*

The dog described herein is registered with a national registry service and I am surrendering.

Yes

I understand that Fila 911 Rescue and Rehab is a 501(c)(3) non-profit organization and I wish to help the organization defray expenses involved with medical and behavioral rehabilitation as well as food, travel, and supplies for the dog. Therefore, I am making a donation of $____________ for these purposes. All donations will be sent through one of these methods: PayPal Venmo:@fila911rescueandrehab CashApp: $FilaRescue Check*

I CERTIFY THAT ALL THE INFORMATION ON THIS FORM HEREIN AND THE SURRENDER APPLICATION THAT WAS SUBMITTED ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

Yes

By typing in my name below as my digital signature, I agree to surrender all ownership, documents, and rights of the above described said dog to Fila 911 Rescue and Rehab. I also give permission to Fila 911 Rescue and Rehab to access all medical records of this dog. I certify that all information on this form and all attachments are true and correct. The undersigned hereby forever releases, discharges, covenants to hold harmless, and indemnify for all costs to Fila 911 Rescue and Rehab or any official agents from any and all claims for damages, expenses, or actions arising out of any act or occurrence pursuant to this contract and/or conduct of said dog.*

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