Owner Surrender Form

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Your Details

Individual

Business/Organization

Business/Organization*

First Name*

Last Name*

Email*

Phone number*

Ext.

Work Mobile Home

Address Line 1

Address Line 2

City

State/Province

Postal Code

Country

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Additional Information For Your Surrender Form(s)

1 X Owner Surrender Form

Dog's Name

Required

Characters Remaining: 500

Breed

Required

Characters Remaining: 500

Sex:

Required

Altered?

Required

Color:

Required

Characters Remaining: 500

Approximate Weight:

Required

Characters Remaining: 500

Cropped ears?

Required

Docked Tail?

Required

Age or birth date:

Required

Characters Remaining: 500

Length of ownership:

Required

Characters Remaining: 500

Why is the animal being given up?

Required

Characters Remaining: 500

Veterinarian Clinic's Name:

Optional

Characters Remaining: 500

Veterinarian Clinic's Address:

Optional

Characters Remaining: 500

ZIP / Postal Code

Optional

Characters Remaining: 500

Veterinarian Clinic's Phone:

Optional

Characters Remaining: 500

On heartworm preventative?

Required

Monthly due date

Optional

Characters Remaining: 500

Up to date on rabies shot?

Required

If yes, county/state/tag number:

Optional

Characters Remaining: 500

Additional vaccines given and dates:

Required

Characters Remaining: 500

Does your dog have allergies?

Optional

If so, to what?

Optional

Characters Remaining: 500

Is your dog on any medication(s)?

Required

If so, which medication(s)? What condition is being treated & how regularly does it occur:

Required

Characters Remaining: 500

Does your dog have any old injuries or health concerns?

Required

If yes, please explain:

Required

Characters Remaining: 500

Has this dog bitten you or anyone else?

Required

If animal has bitten, please explain:

Required

Characters Remaining: 500

Where was this animal acquired?

Required

If from a breeder, please provide name and city of breeder:

Optional

Characters Remaining: 500

Have you contacted the breeder to see if they want to take their dog back?

Optional

Describe the dogs living area (house, outdoor pen, etc.):

Required

Characters Remaining: 500

Number of hours dog was: kept inside, kept outside, left unsupervised?

Optional

Characters Remaining: 500

Where was the dog kept

Optional

Where did the dog sleep?

Optional

Indicate those who lived with this dog:

Optional

If other pets lived in the same home with this dog, list dogs/cats and gender/age:

Required

Characters Remaining: 500

How did the dog get along with the other animals in your household?

Required

Characters Remaining: 500

Were there times you kept the animals separated? Who was the dominant animal in the home?

Optional

Characters Remaining: 500

Who was the dominant animal in the home?

Optional

Characters Remaining: 500

Does your dog have any issues with men/women/children? Please explain.

Required

Characters Remaining: 500

If no, please list the ages you would recommend for this dog:

Optional

Characters Remaining: 500

If a child goes near the dog when it is eating or takes away a toy/bone/etc, would the child be in danger? Please explain.

Optional

Characters Remaining: 500

Describe your household

Optional

Types of training:

Optional

Dog knows how to:

Optional

Dog is frightened of:

Optional

Is there anything that makes this dog show signs of aggression towards people? Please explain

Required

Characters Remaining: 500

Is your dog house broken?

Required

Is your dog crate trained?

Required

Characters Remaining: 500

How often is the dog let out or walked?

Optional

Characters Remaining: 500

How does the dog tell you?

Optional

Characters Remaining: 500

Accidents occur?

Optional

Are the accidents:

Optional

Where have accidents occurred?

Optional

Characters Remaining: 500

How have you dealt with the problem?

Optional

When outside, the dog is:

Optional

If loose, dog will:

Optional

Dog will chase:

Optional

Animals this dog does not get along with:

Optional

Characters Remaining: 500

Has the dog ever killed another animal such as a rabbit or cat?

Optional

When leashed this dog:

Optional

Would you suggest this dog be placed with other big dogs?

Optional

Would you suggest this dog be placed with other small dogs?

Optional

When is the dog fed?

Optional

Dog is fed:

Optional

List brands of food & amount fed:

Optional

Characters Remaining: 500

Any special treats?

Optional

Characters Remaining: 500

Dog’s favorite toys & play activities:

Optional

Any bad habits the new owner should be aware of? (i.e. stealing food off the counter/table, raiding the garbage, etc.)

Optional

Characters Remaining: 500

What has been done to correct the problem?

Optional

Characters Remaining: 500

Which traits best describe this dog:

Optional

The dog is accustomed to:

Optional

Submit a photo of your dog

Required

Formats: File types allowed: PNG, PDF, JPG.
Max file size: 10MB

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Your Details

Additional Information For Your Surrender Form(s)

1 X Owner Surrender Form

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