APLMC Surrender Form
APLMC
P.O. Box 663
Celina, OH 45822
(419) 586-2887
info@aplmercer.com
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Dog's Name:
*
Dog's Age:
*
Dog's Weight:
*
Dog's breed or mix of breeds:
*
Pet's Gender:
*
Male
Female
Is dog spayed/neutered:
*
Yes
No
Is the dog up-to-date on vaccinations?
*
Yes
No
Is the dog on heartworm prevention?
*
Yes
No
Does the dog get along with other dogs?
*
Yes
No
Does the dog get along with cats?
*
Yes
No
Is the dog good with kids?
*
Yes
No
Is your dog a runner?:
*
Yes
No
Does the dog have a microchip?
*
Yes
No
Does the dog have separation anxiety?
*
Yes
No
If yes, please explain:
Is your dog kept inside or is it an outside dog?
*
Is your dog housetrained?
*
Yes
No
Is your dog crate-trained?
*
Yes
No
Where did you get the dog from?
*
Rescue
Dog Pound
Breeder
Other
If you selected other, please explain how you aqquired the dog:
Are there any behavioral or health problems? Please explain in detail:
Has the dog ever bitten or shown aggression to anyone or any other dogs/animals?
*
Yes
No
If yes, please explain?
Why are you rehoming your dog?
*
How long can you keep the dog while we try to find a home for him/her?
*
Please provide your current or previous vet clinic's name, address, and phone number:
*
Please upload a current picture(s) of your dog:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: