Owner Surrender Form

Your responses will not determine if we can or cannot help, but will guide is in finding an appropriate home for the dog. For this reason, we implore you to be as honest as possible in all responses. Completing and signing this form does NOT bind us to accepting the dog into our care.
Date

Month Day Year
Date
Name of dog
Age
Breed
Weight
Sex
Microchip #
Color(s) of dog
Amount of time you have been the owner
Where did you get the dog from
Reason for Surrender
How long do we have to find placement
Medical Information
Name of veterinarian/animal hospital
Address
City/Town
State
Zip
Date of last vet visit

Month Day Year
Date
Scars, Tattoos, or Injuries
On Heartworm Preventative?

Yes No Other
Brand of Heartworm prevention
Date last administered

Month Day Year
Date
Current on Rabies Vaccine?

Yes No
Date of last Rabies vaccine

Month Day Year
Date
Current on DHLPP?

Yes No
Date of last DHLPP

Month Day Year
Date
Current on Bordetella Vaccine?

Yes No
Date of last Bordetella vaccine

Month Day Year
Date
Date dewormed

Month Day Year
Date
General Information
Type and/or brand(s) of dog food in diet
How often and when do you feed the dog
Frequency needs to be walked
Crate Trained?

Yes No Other
Housebroken?

Yes No Other
Is the dog friendly with other dogs?
Is the dog friendly with cats?
Is the dog friendly with strangers?
Dog's experience with children?
Explain any training the dog has, if any, and techniques used
Any behavioral issues, specific fears, traumatic experiences, etc.
Release of Ownership
I agree and understand that I am giving up all rights of possession and ownership of this dog.

I also understand and acknowledge that I will not be able to redeem said dog at any time. I agree and understand that said dog is now "sole property" of Twenty Paws Rescue I further agree to submit any and all medical information. I promise that all the information I provide is accurate and Twenty Paws Rescue will not be held liable or chargeable for any false information or misrepresentations that I submit on this from. Furthermore, I truthfully and honestly complete and sign this Owner Surrender Form as said dog's sole or primary owner. I am not surrendering a dog that belongs to any other person, firm, or organization.
Print Name
Signature

Clear
Date

Month Day Year
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Driver's License#
D.O.B.
The undersigned acknowledges that they have:

1) Read this agreement in its entirety

2) Had the opportunity to see the advice of counsel

3) Fully understand the agreement

4) Execute this agreement voluntarily and of their own free will

5) Are completely authorized to enter into the terms of and conditions of, and be bound by, this agreement.
Should be Empty:

Medical Information

General Information

Release of Ownership