Basset Hound Rescue League, Inc.(BHRL)
P. O. Box 44201
Fort Washington, MD 20744
Phone- 301-292-3020 /Fax- 301-292-1555 /email- wrdcld@cs.com
Bite Disclosure Form
Date of bite:__________________
Who was bitten?:__________________________ Age:______
What part of the body was bitten?_____________________
Was medical attention required?(If yes, attach copies of reports)
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Was bite reported to the authorities?_________________
If yes, what authorities? (Attach copies of any official reports)
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Please explain in full detail the circumstances of the biting incident:
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I hereby acknowledge that I have read and understand the above terms and conditions, and that all information provided herein is complete and correct.
Name (print):_____________________________________________________
Address:__________________________________________________________
City/State/ZIP:___________________________________________________
Signature:________________________________________________________
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