I, _______________________________, an adult, do hereby voluntarily and irrevocably give, donate, surrender and release to Cherished Cockers, hereinafter referred to as CC, 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 CC. No other person has any legal or equitable ownership interest in the Animal(s).

I have disclosed to CC 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). CC 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:__________________________________________________________________

City, State zip: _____________________________________________________________

Telephone Number_________________________________________________

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

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

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

____________________________________________________________________________________

I understand that by releasing the Animal(s) to CC, 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 CC for details. My contact with the Animal(s) terminates at the time of surrender. CC is under no obligation whatsoever to follow up with information about the Animal(s).

I hereby release and forever discharge CC from any and all rights, claims, obligations, liabilities and causes of action whatsoever arising out of relating to the ownership, possession, or disposition of the Animal(s), and I agree to indemnify and hold harmless CC 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 CC.

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:_______________________________________________________

City, State zip __________________________________________________________________

OWNER'S TELEPHONE NUMBER(S)__________________________________________

OWNER'S EMAIL ADDRESS:_________________________________________________

WITNESS:_____________________________________________________________________

CC AGENT TAKING CUSTODY:__________________________________________________

Cherished Cockers
C/O Christine Bacon
8216 Rushton Drive
Mentor, Ohio 44060-2025