Shelter to Rescue Transfer Request

Personal info:

Name:*

Email Address:*

Phone Number*

Shelter Information:

Organization Name:*

Organization Phone if different from above:

Contact Person if other than yourself:

Street Address*

Street Address Line 2

City:*

State:*

Postal Code:*

Hours of Operation:*

Does the shelter have a Facebook page?*

Shelter's Facebook Page URL:*

What vaccinations do dogs receive prior to placement with rescue?*

Does the shelter charge a rescue fee?*

If yes, what is the amount of the shelter fee?

Information on the Dog(s):
Pictures (in JPEG format) of the dog(s) should be attached below

Dog #1 Name:*

Dog #1 ID #:*

Dog #1 Age:*

Approximate Weight of dog:*

Dog #1 Sex*

Is Dog #1 Pure-bred?*

Was dog #1 an Owner Surrender or Stray?**

*If the dog was an owner surrender, please provide owner surrender form with owner's information redacted.

Is the dog spayed or neutered?*

Will dogs be spayed or neutered prior to placement with rescue?

Is the dog microchipped?*

YesNo

If microchipped, what is the microchip number?

Our board voted recently that we must know the heartworm status of dogs before we can accept them into our program. A positive test result will not result in automatic dismissal from consideration; however, our budget does limit the number of hw + dogs we can treat.

Has the dog been Heart Worm tested?*

Was the test positive or negative?*

If not tested, will the dog be Heart Worm tested?

Dog #1 Kill Date:*

Does dog seem to get along with other dogs?*

Does dog seem to get along with cats?*

Does dog seem to get along with kids?*

Dog #1 Comments:

Dog #2 Name:

Dog #2 ID #:

Dog #2 Age:

Approximate Weight of dog:

Dog #2 Sex:

Dog #2 Pure-bred:

Is the dog spayed or neutered?

Was dog #2 an Owner Surrender or Stray?

Has dog been microchipped?

YesNo

If microchipped, what is the microchip number?

Has the dog been Heart Worm tested?

Was the test positive or negative?

If not tested, will the dog be Heart Worm tested?

Dog #2 Kill Date:

Does dog seem to get along with other dogs?

Does dog seem to get along with cats?

Does dog seem to get along with kids?

Dog #2 Comments:

Dog #3 Name:

Dog #3 ID #:

Dog #3 Age:

Approximate Weight of dog:

Dog #3 Sex:

Is dog spayed or neutered?

Dog #3 Pure-bred:

Was dog#3 an Owner Surrender or Stray?

Is dog microchipped?

YesNo

If microchipped, what is the microchip number?

Has the dog been Heart Worm tested?

Was the test positive or negative?

If not tested, will the dog be Heart Worm tested?

Dog #3 Kill Date:

Does dog seem to get along with other dogs?

Does dog seem to get along with cats?

Does dog seem to get along with kids?

Dog #3 Comments:

Dog #4 Name:

Dog #4 ID #:

Dog #4 Age:

Approximate Weight of dog:

Dog #4 Sex:

Is dog spayed or neutered?

Dog #4 Pure-bred:

Was dog#4 an Owner Surrender or Stray?

Is dog microchipped?

YesNo

If microchipped, what is the microchip number?

Has the dog been Heart Worm tested?

Was the test positive or negative?

If not tested, will the dog be Heart Worm tested?

Dog #4 Kill Date:

Does dog seem to get along with other dogs?

Does dog seem to get along with cats?

Does dog seem to get along with kids?

Dog #4 Comments:

Dog #5 Name:

Dog #5 ID #:

Dog #5 Age:

Approximate Weight of dog:

Dog #5 Sex:

Is dog spayed or neutered?

Dog #5 Pure-bred:

Was dog#5 an Owner Surrender or Stray?

Is dog microchipped?

YesNo

Has the dog been Heart Worm tested?

Was the test positive or negative?

If not tested, will the dog be Heart Worm tested?

Dog #5 Kill Date:

Does dog seem to get along with other dogs?

Does dog seem to get along with cats?

Does dog seem to get along with kids?

Dog #5 Comments:

Other Comments About These Dogs:

How did you hear about Southern States Rottweiler Rescue, Inc.?*

Pictures:

Please include a few pictures, especially a nice head/face shot with ears forward. Please don't size them smaller than about 500 pixels or 7" wide. JPG format is preferred. Don't worry if if they are too big or off center.

If your photos are too large for this form, email them to rottie.info.ssrr@gmail.com. Not including photos will delay the Intake process.

Photo #1:

Photo #2:

Photo #3:

We reserve the right to refuse acceptance of any Rottweiler. Acceptance is based on many criteria, one of which is space availability. If you are out of our area, we will pass on your surrender form to another rescue.

I understand that the information contained in this form might be passed on to another rescue*

Additional Comments:

I certify that the information provided on this form is true & correct. I understand that an physical evaluation of the dog by an experienced rescue volunteer will be required before we accept surrender. If upon inspection we find that information contained in this surrender form to be false, we retain the right to turn down acceptance of the surrender at anytime during the evaluation.

Signature (re-type email address):*