Surrender Application
No Mutts Left Behind, Inc.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Dog's Name:
*
Dog's Gender:
*
Spayed/Neutered?
*
Dog's Age and date of birth:
*
Dog's breed/color:
*
Where did you get this dog? (breeder, rescue, etc.)
*
Contact info from breeder, rescue or previous owner:
How long have you lived with this dog?
*
Is the dog microchipped?
*
Current Vet name, address, phone number:
*
Is you dog up to date on vaccinations? (DHLPP, Rabies, Bordetella, Lyme)
*
Date of last heartworm test and results:
*
Is your dog up to date on heartworm prevention? What brand?
*
Is your dog up to date on flea/tick prevention? What brand?
*
Is your dog currently on any medications? If so, please list:
*
Any other health concerns (thyroid, allergies, seizures, broken bones, special diet, etc.):
*
Does your dog know basic obedience commands? (sit, come, down, stay)
*
Does your dog show signs of separation anxiety?:
*
Please explain any behavior/aggression issues:
*
Has your dog completed any training classes with a trainer? If yes, with who and how long ago?
*
Does your dog like other dogs?
*
Does your dog like cats?
*
Does your dog like children?
*
Does your dog interact with men?
*
Does your dog interact with women?
*
To your knowledge has your dog ever been exposed to an abusive home or neglect?
*
Has your dog ever bitten anyone? If so please explain:
*
Is your dog aggressive towards other dogs or people? If so, please explain:
*
What is your dog currently eating for food?
*
Where does your dog sleep?
*
Where does your dog stay while you are gone?
*
Does your dog jump baby gates or fences?
*
Why are you looking to give up or re-home your dog?
*
When does your dog need a new home?
*
Submit
Should be Empty: