Rescue to Rescue Transfer Request

Personal info:

Rescue Transfering Dog*

Full Name*

First NameLast Name

Age:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Email Address:*

Phone Number*

Dog Info:

Where is the dog located?*

City/State:

If you have more then one dog to surrender, than fill out one application for each dog, making sure your name and email address are on each application. If we have any further questions, we will contact you by phone or by email.

Please tell us why you want to transfer this dog to SSRR. Please be specific.*

Name of Dog:*

Sex of Dog:*

Age of Dog:

Date of Birth if known:

Age is unknown, but approximately: *

Approximate Weight of dog:*

Is the dog Spayed or Neutered?* *

If the dog has Not been spayed or neutered are you willing to pay to have it done?*

Does the dog have a tail*

Other Comments:

Please provide the following information to the best of your ability:

Medical History

If you are the present owner of this dog, please provide information about the dog's veterinarian:

Veterinarian's name:

Veterinarian's Phone Number:*

Is the dog microchipped?

YesNo

If microchipped, what is the microchip number?

Has the dog been tested for heartworm?**

If Yes, test was:

If the dog has not been tested for heartworm are you willing to have this done?

If the dog is heartworm positive are you willing to pay for the heartworm treatment?

Is the dog currently on heartworm preventative medication?*

If yes, what brand of heartworm medication has the dog been on?

If not, when was the last date that heartworm preventative was given?

Is this dog current with it's vaccinations?

If not, are you willing to have the dog given all his vaccinations?

Please provide other details of known/suspected medical conditions of this dog.

Is the dog an Inside Dog/Outside Dog/Not Sure?*

Other Comments:

Behavior

Is the dog housebroken?* *

This dog:* *

Explain above answer:

Will the dog allow you to examine it's body without much trouble?*

How does the dog behave around adults?*

Is the dog good around children?*

Has the dog ever bitten or snapped at anyone?*

If Yes, please explain & Please be specific.

Has the dog ever shown any aggression towards anyone or another animal?*

If Yes, please explain & Please be specific.

How does the dog behave at the vet?

Please explain & Please be specific.

Is the dog good and well socialized around male dogs?*

Is the dog good and well socialized around female dogs?*

Is the dog good and well socialized around small dogs?*

Is the dog good and well socialized around cats?*

Is the dog good and well socialized around livestock (Cows, Horses, Pigs, Chickens, Ducks)?*

If you selected No in any of the 6 items above to do with other animals, please explain & be specific:

Is the dog overly possessive about his food/treats/toys?*

Please tell us about other behavior issues this dog may have.*

Please list any commands the dog has knowledge of.*

When on a leash, do you walk the dog? or does the dog walk you?**

Has the dog been Guard or Protection Trained?*

Other Training Comments:

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.

Photo #1:

Photo #2:

Photo #3:

Photo #4:

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 Rottweiler 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):*

example@example.com