Surrender Application

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: *

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? *