Date:

 

 

 

First Name:

Last Name:

Address:

 

City:

State:
Kansas AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code:

 

Phone Number:

Days until I get my pet spayed:

Dog Tag #:

Pet's Name:

 

Spay/Neuter Deposit:

Other fees (Do NOT Include $ Symbol):

Total:

 

I, , am adopting a dog from the City of Leoti pound located at 401 N. Wichita St. By signing below, I promise to have this pet spayed or neutered at my expense. I will pay a $55.00 deposit for this procedure, refundable upon proof of surgical procedure from veterinarian of my choice. I will be given days to get this done.

RELEASE
I, , accept the animal, , from the Leoti City Pound as is and assume all risks of it ownership, including the risk of injury or damage caused by the animal, on behalf of myself, my heirs, personal representatives, and assigns. I hereby release, discharge, indemnify, and hold harmless the City of Leoti and its directors, officers, employees, councilmen and agents from any claims, causes or action, and demands of any nature, whether known or unknown, arising out of or in connection with my adoption, care and ownership of the animal, including without limitation any treatment or handling of the animal by veterinarian, or other provider.

This agreement may be specifically enforceable by the City of Leoti through judicial proceedings. In the event that I breach this agreement I will pay any court costs and attorney fees incurred by the City of Leoti in connection therewith.

---

Owner's Name:

Date:

 

SUBMIT FORM