Responsibility and Liability Disclaimer
for Animal Referrals and Placements

1. I / We the undersigned agree to indemnify and hold harmless the ASA, its members, agents, employees, volunteers, and Board of Directors, against any and all liability arising from an animal(s) who is referred by ASA to a member or non-member organization. ASA will not be held responsible should the animal:

a. Injure or inflict death on a member of the public, during transport or on the grounds of the receiving facility, escapes during transport, or escapes from the grounds of the receiving facility.

b. Sustain injury during transport or at the receiving facility.

c. Die during transport or at the receiving facility.

2. ASA will not be held responsible should a member organization dissolve its operation while housing animals that have been referred by ASA. ASA will attempt to find alternative placements if the animals are abandoned. However, the ASA will not be held liable for any debts incurred by these animals.

3. It is further agreed that animals referred to you by ASA and accepted for placement shall not be bred, sold, traded, or used for any commercial purpose.

Name of Organization:____________________

Name of person(s) responsible for animal placements:____________________

Address:____________________

City:_______________

State:_____

Zip:_______

Tel #_______________

Fax#_______________

Email Address:_______________

Date:__________

Signature:____________________

Title:____________________

State of____________________

County of____________________

Subscribed and sworn to and before me on this_____day of _____year_____