Surrender Form

We try our best to help with local surrenders, and understand that people may not be able to afford to pay the full amount we request to surrender an animal. We do ask that you give what you are able to help offset the cost of medical care (if needed) and for taking care of the surrendered animal until such time as we can find an appropriate adopter. Please fill in the amount that you can give in the field at the bottom of this form, if you are able to do so.
Owners Name(s)*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Is this an animal that you adopted from Blessed Be the Bullies?*

YesNo
If the answer is yes, please put the approximate date you adopted your animal, and their name prior to adoption if you have changed it. If no, please put N/A*
Approximately how old is the animal? Please put DOB if known. *
Please provide the name of a personal (non related) reference who is familiar with your animal and your situation. *
Please provide the phone number for the above listed reference. *

Area CodePhone Number
How did you hear about Blessed Be the Bullies?
Name of Animal?*
Why are you surrendering this animal?*
Type of Animal?
Why are you surrending this animal?*
If we could help resolve this issue, would you be interested in keeping your animal?*

YesNo
Have you tried contacting or working with a professional trainer?*

YesNo
Has this animal ever bitten anyone that you know of?*

YesNo
If yes, please describe the circumstances if known.
If yes, was the incident documented by law, animal control or public health?

YesNoUnsure
If yes, please provide a brief description of report such as date and location if known.
Has this animal seen a veterinarian at least once per year?*

YesNoUnknown
Is this animal up to date on vaccines?*

YesNoUnknownOther
Is the animal spayed or neutered?*

SpayedNeuteredUnknown
Name of current veterinarian (If no vet, put N/A) :*
Address Of Veterinarian*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number for vet: (PLEASE CALL AND GIVE THEM PERMISSION TO SPEAK TO US)*

Area CodePhone Number
Please make arrangements with your vet if possible to forward your pets records to us at blessedbethebullies@gmail.com.
Has this animal ever required surgery or been diagonosed or treated for any medical problems?*

YesNoUnknown
If yes, please explain:
Have you noticed any coughing in your animal in the past week?*

YesNoUnsure
Is your animal currently receiving any medications? *

YesNo
If the answer above is yes, please elaborate with type of medication and dosage.
Is your animal currently being treated with preventatives for fleas and ticks?*

YesNo
Has your animal been tested for heartworm in the past year?*

YesNoUnsure
If the answer is yes, please give the date of testing if known.
In the last 7 days has your animal been in contact with other animals in a rescue/shelter or daycare/boarding situation?*

YesNo
In the last 7 days has your animal been in contact with other animals at a groomer, dog park or vet clinic?*

YesNo
Is your animal on a prescription diet?*

YesNoWhat brand of food are they currently on?Other
Which type of food does your animal currently eat?*

DryWet (Canned)Combination
How often is your animal fed? Please check all that apply:*

Once a dayTwice a dayFree FedTraining TreatsPeople food/snacks
Is your animal currently housebroken?*

YesNoIn training
Has your animal received any obedience training?*

YesNoIn training
If yes, from what trainer and what methods were used (if known):
What are the basic commands your animal knows? Please check all that apply.

SitStayDownComeHeelDrop ItNoOther
What are the basic commands your animal knows? Please check all that apply.*

SitStayDownComeHeelNoOther
When walking your animal, what equipment do you use?

flat collarhead collarfront clip control harnesspressure collarlimited slip collarprong collarchoke chainelectric collar
When exercising your animal, what equipment do you use?*

Flat CollarHead collar or muzzleFront clip control harnessPressure CollarLimited slip CollarMartingale CollarProng Collar or Choke ChainOther
How is your animals behavior off from the leash? *
Is your animal used to being in a fenced yard?*

YesNoUnknown
Will your animal chew or destroy household items when left alone?*

YesNoUnknown
What is your dogs barking pattern?*

Alarm onlyFrequentlyAt anything:
Please elaborate if possible:
How would you describe your animals personality?*

Very ActivePlayfulAffectionateFriendly to VisitorsCouch PotatoShy to VisitorsDistantTalkativeQuietFearfulIndependentAgressiveOther
How does your animal like to play? (For instance, fetch/tug of war, chase, etc.)
Does your animal get along with dogs?*

YesNoSomewhatOnly when supervisedUnsure
Does your animal show a preference for male or female dogs?*

MaleFemaleBothNeitherUnsure
Does your animal get along with cats?*

YesNoUnsure
If there has been an issue in the past with your animal and another, please provide details: Skip if not applicable
Has your animal regularly been around children?*

YesNoUnknown
Have experiences with children been positive?*

YesNoUnknown
Please indicate ages of children and if there were any issues please describe: Skip if not applicable
Is the animal most comfortable around (please check all that apply)*

MenWomenChildrenTeensSenior CitizensAll People
Please decribe some things you feel your animal dislikes:*
Please describe some things you love about this animal!*
Are there any quirks or habits you are not fond of in your animal? This information may help rescue staff with valuable insight and can help ensure a successful adoption. Many "quirks" are common behaviors and may have simple resolutions. *
Is there anything else you feel that we should know about your animal? Skip if not applicable, but all the information you can supply will help us find the best home for your animal.
For reference, in the following document Blessed Be the Bullies and its owner, employees and/or volunteer members may be referred to collectively as Blessed Be the Bullies or BBTB.

By sending this electronically, I acknowledge that I have completely read this questionnaire and comprehend it fully.

I certify that the above information is correct, and I understand that the information will be verified.

I understand that by submitting this form electronically, I agree to release and covenant to hold harmless Blessed Be the Bullies Rescue and it's members from any claims, damages, costs, or actions incurred because of the care or actions of the animal in question.

I agree that by signing this form, I am relinquishing all rights, responsibilities and future considerations to the animal in question.

I certify that I am the current and responsible owner of this animal, and that there are no other bonds or ties to this animal by any other person(s).

Our suggested fee is $250 for animals that are not altered or up to date on their vaccinations. This helps cover the cost of having them vetted before we find them a new home.

A suggested fee of $150 is asked for dogs that are altered and up to date on vaccinations. This will help feed and house them while we find the perfect adoptive family.

Blessed Be the Bullies is a non-profit, 501c3 foster based rescue in Lewiston Maine, soley in the rescue industry to save animals and find them loving forever homes. BBTB relies on donations and it's own fundraising efforts for it's continued survival. In order for our doors to remain open the continued support of the community is essential.
By initialing in the box below, I certify that I have contacted the rescue directly about my animal BEFORE completing and submitting this form. *
If your animal did NOT come from our rescue, please continue with this question. If they did come from BBTB, put N/A in the box. By initialing in the box below, I certify that I understand that although Blessed Be the Bullies will do it's best to help me find a new home for my pet, that they are under no obligation to take possession of my animal, and that it is my responsibility to take care of the animal until such time as the rescue may be able to help. *
I have disclosed all medical information and needs of the animal I am surrendering to the best of my knowledge. I certify that the animal I am surrendering does need any medical care over and above basic vaccinations or spay/vaccination, or if they do need more care that I have been transparent with the rescue of these needs.
Please type your full name in this field to indicate your understanding and agreement of the statement about medical information above. *
Date

MonthDayYear
Your name typed in the box below serves as your binding signature on this document, and signifies that you have read, understand and agree to any terms contained within. *
Signature (free form sign using mouse or fingertip)*

Clear
Please fill out the form below so that if you are not able to either send the current records yourself or are unable to request them from your vet, that we may obtain the records for your animal from the veterinarians office. Thank you.
I, Ownerhereby request that Vets Office release any and all information pertaining to Animal Name contained in the veterinary records to Blessed Be the Bullies and it's representatives. This request and authorization is limited to the above noted agency. This shall be considered your good and sufficent authority for doing so. Date*
Owner Name and signature: Owner Name Signature
Suggested Donation is at least $150 for fully vetted animals, or at least $250 for animals who need to be spayed or neutered, or brought up to date on vaccinations.

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USDSuggested Donation is $150 for a fully vetted animal, or at least $250 for an animal who needs updated vaccinations and or altering.
If PayPal is chosen for a payment option, please ONLY choose PayPal when the payment box pops up. Do NOT choose Venmo or Pay Later, you will lose your information entered in the form and have to start over.

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