Owner Surrender Submission Form

Owner Surrender Submission Form

Submission of this form does NOT guarantee that NCCR will take the dog into the rescue. We will review the form and reach out if we are able to post the dog to try to find an available foster. We will do our best to respond, but you may not hear back from us if we are already at capacity.
Owner's Name Surrendering Dog*

First NameLast Name
Mailing Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
*The information you provide on this form will help us match your dog with an appropriate new home. Please be honest in your answers. NCCR accepts dogs based on temperament and available fosters*
Dog's Current Name*
Nickname
Name of the dog when you adopted it (if adopted)
Current age*
Date of Birth*
MM/DD/YYYY
Male or Female*
Approx Weight*
Spayed or Neutered*
What age was the dog spayed or neutered
Where was the dog spayed or neutered
Name and Phone Number
Breed*
Current Veterinarian*
Name and Phone Number
Date of last visit at vet*
Last vaccination for Rabies/ Distemper Parvo*
Does the dog have health issues?*
If yes, please describe
Last heartworm test and last date of heartworm preventative medication *
Current medication/ last date given (Including flea/tick)*
Were you this dog's first owner?*
Where did you get this dog?*
Is this dog good with other dogs?*
Is the dog good with children? YES, NO or UNKNOWN*
Please explain
Is the dog good with cats? YES, NO or UNKNOWN*
Please explain
Has this dog ever bitten anybody? YES, NO or UNKNOWN*
Please explain
Does this dog show aggression over food or toys or been in a fight with another dog? YES, NO or UNKNOWN*
Please explain
Where does this dog sleep at night?
Is the dog house trained? (meaning, does it go to the bathroom outside?)
Why are you surrendering the dog?*
Please Explain
Are you willing to make a donation to Nickel City Canine Rescue if the dog is surrendered to us?*
Please include a few of the best and recent photos of your dog

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I certify that I am the legal owner of this dog. I ensure that the above information is accurate. In the event that NCCR accepts the dog into the rescue and the information in this contract is found to be false, NCCR has the right to rescind this contract and seek liquidated damages in the amount of $1,000. I understand that if the dog is surrendered to the rescue, that myself, my spouse and any other co-owners of the above described dog are irrevocably transferring and relinquishing to Nickel City Canine Rescue legal ownership of said dog on the date of surrender/acceptance. This gives NCCR complete authority to take whatever actions in their sole judgment are necessary and in the best interest of the dog. *

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