DOG OWNER SURRENDER APPLICATION

Name *

First Name Last Name

Street Address *

City *

Zip_code *

Phone *

Email *

example@example.com

Animals with vet records: $50 Intake Donation Requested. Animals without vet records $100 Intake Donation

Reason for Surrender *

Name *

Breed *

Gender *

Age and Date of Birth *

Spay/Neutered? *

Yes No

Color

Distinguishing Marks

Has this dog bitten a person or another animal in the last ten days? *

Yes No

Has this dog bitten a person or animal any time in the past? *

Yes No

Where does your dog spend most time? Indoors, outdoors or both? *

Is your dog housetrained? *

Yes No Uses puppy pads in house

House training comments

Who is your Veterinarian? *

Do you have vet records? *

Yes No

Does your dog have allergies? If yes, please explain. *

Does your dog need medications? If yes, please explain. *

Does your dog have special needs? If yes, please explain. *

Check all that Apply:

My dog has been crated. My dog has been muzzled. My dog needs to be muzzled before going to the vet or being groomed.

How long have you owned your dog? *

Where did you get your dog from? *

Tell us about how much training history your dog has. *

None, minimal, fully, extensive

Does your dog know any commands? If yes, please list here.

My dog enjoys (check all that apply) *

My dog is afraid of (check all that apply) *

My dog, off leash is:

Completely reliable Somewhat reliable Not at all reliable Unknown

Activity Level: Please chose one. *

Low Moderate High

Stairs:

Able to climb up Able to climb down 4 or less Full staircase I can carry my dog up or down the stairs if needed My dog needs help in and out of the car My dog needs a ramp, step stool or to be picked up and placed in the car

Eating:

My dog eats at specific times. My dog is allowed to eat all the time (free fed).

Brand of dog food my dog will eat.

Please check all that apply: *

Do you have any additional comments about the pet's interaction with people?

Do you have any additional comments about the pet's interaction with animals?

Once you surrender your pet it will undergo standard behavior testing and we will determine the best course of action - whether placement for adoption, transfer to a specialized rescue group, or euthanization due to health or temperament.

I hereby certify that am the rightful owner/keeper/caretaker/custodian of the animal(s) who is/are the subject of this Animal Surrender form, hereinafter referred to as "animal." I hereby surrender any and all property rights to the animal. Icertify that no other person has a right of property to the animal. I understand that by surrendering my property rights to the animal, the animal may be transferred into the custody of another animal shelter. I also hereby certify that the animal has/has not (circle one) bitten or scratched a human or another animal within the past 10 days. I understand that once I relinquish the animal, the animal will not be available to be returned. I further certify that I have read and understand the terms of this animal surrender form.

Signature of Owner *

Clear

Date *

Date

Signature of Health and Welfare Chair

Clear

Date

DOG OWNER SURRENDER

OWNER/GUARDIAN INFORMATION

ANIMAL BASIC INFORMATION

PROFILE INFORMATION