CCFR Surrender Form

Date *

Month Day Year
Date
Pet's Name *
Why are you surrendering or returning this pet? *
Are you *

surrendering this pet to CCFR Returning this pet to CCFR (proceed to last paragraph if you've had this pet less than 6 months)
Are you the legal guardian of this pet? *

Yes No
How long have you owned this pet? *
Current Owner's Name *
Current Owner's Address *
Day time phone # *
Email *
example@example.com
Have you ever surrendered a pet to a shelter or rescue in the past *

Yes No
If Yes, please list the pet, where surrendered, and circumstances
Microchip registration number
Color/Pattern
Age *
Date of Birth

Month Day Year
Date
Approximate weight of dog *
This dog is

Male Female Spayed or Neutered Unaltered
What breed(s) is this dog? *
Breeder or Where obtained (name, address, kennel, shelter)
Veterinarian Clinic/Name *
Address
City
State
zip code
Vet phone *
Date of last annual shots *

Month Day Year
Date of last Vet visit *

Month Day Year
Date of last Rabies vaccine *

Month Day Year
Name of County
Rabies tag #
Date of last Bordetella vaccination *

Month Day Year
Date of last Heartworm check *

Month Day Year
Results of Heartworm test? *

Negative Positive Has the dog ever been treated by a vet because it had heartworms?
If yes, please list date *

Month Day Year
What is the name of dog's Heartworm preventative he is currently on? Next dosage due on
Are you currently treating your dog for fleas? *

Yes No
If yes, what brand of flea product
Has your dog been or being treated for *

back problems diabetes Cushing's disease Addison's disease Epilepsy other seizure disorders heart/cardiovascular issues frequent urinary tract infections obesity Other
Does the dog require medication for any temporary or ongoing problem? *

Yes No
Does the dog suffer from allergies? *

Yes No
If yes, what is the dog allergic to?
Has your dog ever had a major injury or surgery? (broken bones, back injury, surgery other than neutering?) Please explain. *
Please list some of the dog's favorite games and toys (tug of war, fetch, etc) *
List any formal training (obedience, tracking, agility)
Have you (or anyone) ever used harsh corrections, an electronic, citronella, prong, or bark collar, or any other aversive training technique on this pet? *

Yes No
If yes, please describe
It is important that you list any and all behavioral problems. We want your pet to go to a good, permanent andloving home. To do this, we need to know as much about its good and bad traits as possible. How is the dog's temperament around:
Other dogs? *

Good Fair Poor Not Sure
Cats? *

Good Fair Poor Not Sure
Children under 10 y/o? *

Good Fair Poor Not Sure
Strangers? *

Good Fair Poor Not Sure
Do you often have people visit your home? *
Please list at least 2 good qualities that the dog displays *
Please list at least 2 bad habits the dog displays *
Where does the dog sleep? *
With whom? *
Is the dog housebroken? *

Yes No Semi
How many hours can the dog be trusted to not "go" in the house if left alone? *
If male, is the dog marking?

No Semi Yes
What are the dog's normal times for going outside? *
What word do you use to tell the dog to "do its business?" *
Does the dog have an aversion to wet grass, rain, snow etc. ? *
Does the dog have any fear problems with thunder? Loud noises? Objects (sticks, brooms anything that would cause the dog to be fearful) *
Is the dog crate trained? *

Yes No
Baby gate trained? *

Yes No
X-pen trained? *

Yes No
Is the dog home alone by himself while you are at work or otherwise away? *

Yes No
How does the dog usually spend the day *

roams free crate confined to a certain area of the house garage free outdoor fenced chained outdoors Other
Does/can the dog use stairs regularly? *

Yes No Unsure Other
What brand of dog food are you currently using? *
*

canned dry combination
Approximate amounts per each meal (ex. 1 cup) *
Mealtimes *
Please list the dog's favorite chews and treats *
Does the dog tolerate baths? *

Yes No Unsure
Does the dog tolerate nail trims? *

Yes No Unsure
Any special grooming procedures? *
List of possessions transferred with pet *
Other information that helps us find the perfect home *
Please check these statements and initial
REQUIRED for both returned dogs and surrendered dogs.
I certify that the dog described in this document that is being surrendered HAS NOT bitten any human or animal within the last 30 days.   *
* .
HAS bitten an animal in the last 30 days   *
* .
This dog HAS bitten a person in the last 30 days. Please elaborate the reason or the conditions that this incident happened.   *
blank* .   *
I hereby declare that I am the legal owner of dog that is being surrendered and I am willingly surrendering the dog to CO Corgis and Friends Rescue, herein known as CCFR, and that I have indicated all information possible to ensure the continued happiness of this dog and understand that CCFR will place the dog in a loving and permanent home. I understand that I am relinquishing my present and future rights to this dog and may not request the new whereabouts of this dog once I relinquish ownership. To the best of my knowledge I have divulged any and all behavior, physical or emotional problems to CCFR so they may seek a home for the dog's continued happiness and well-being. I will relinquish all material pertinent to this dog including veterinary history and any possessions that would benefit the dog in helping with a smooth transfer to its new home.

I HEREBY AGREE TO THE ABOVE AND SURRENDER ALL MY INTEREST IN THIS DOG TO CCFR AND ITS AGENT TO BE ADOPTED TO A NEW HOME AT THEIR DISCRETION.
Former Owner's Signature *

Clear
Date

Month Day Year
Date
CCFR Representative
Date

Month Day Year
Date
Should be Empty: