I have made an application to Houston Area Doberman Rescue to adopt a Doberman Pinscher.  As a part of the application process, the Houston Area Doberman Rescue interviews references I list on the application form.  I have listed you as one of the references.  You will be contacted by a representative of Houston Area Doberman Rescue.

I am hereby requesting that you furnish to Houston Area Doberman Rescue any information or documents they request and respond to any questions they may ask.

I hereby waive any confidentiality and the confidential relationship between a veterinarian and a veterinarian’s client that may exist pursuant to Texas Occupations Code section 801.353 or any other relevant federal law or Texas statute.  This waiver is given pursuant to section 801.353 (b) (1).

Consent is hereby given for Houston Area Doberman Rescue and its authorized representatives to use the information provided to determine if they will place a Doberman Pinscher with me.  I understand that their decision is final and I have no recourse to appeal that decision.

I hereby waive any right or opportunity to read or review any information, documents, statements, etc. furnished to any representative of Houston Area Doberman Rescue during the course or scope of their investigation pursuant to my application to adopt a Doberman Pinscher from them.  I further waive any right or opportunity to read or review any investigation report prepared by any representative of Houston Area Doberman Rescue.

I hereby release you and anyone representing you or furnishing information pursuant to this request from any and all claims of liability for damage, loss, or injury of whatever kind, which may at any time result to me because of your compliance with the authorization and request to release information or any attempt to comply with it.

I hereby release any member or representative of the Houston Area Doberman Rescue from any and all claims of liability for damage, loss or injury of whatever kind, which may at any time result from the use or consideration of the information provided or from any decisions made in regard to any adoption application I have made to them.

A copy of this authorization for release shall have the same force and validity as the original.

I HAVE READ AND UNDERSTAND ALL INFORMATION CONTAINED IN THIS AUTHORIZATION FOR RELEASE AND CONSIDERATION FOR ADOPTION AND ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF IT.

Applicant Information

Signature

If you are using a phone or tablet to complete this application, simply sign your name below. If you are using a computer, use your mouse to write your name below.

Click submit once. It may take up to 30 seconds for the screen to change. Do not click submit more than once.