Owner Relinquish Application

Owner Relinquish Application

Owner Name*

FirstLast

Address*

Street Address

Street Address Line 2

CityState

Postal / Zip CodeCountry

Home Phone*

Area CodePhone Number

Cell Phone*

Area CodePhone Number

E-mail*

Name of Dog*

Breed of Dog*

Age of Dog*

Gender*

MaleFemale

Has this dog been altered*

SpayedNeuteredNone of the Above

Coat Color*

Coat Length*

How long have you owned this dog?*

Where did you acquire this dog?*

House trained?*

YesNo

Crate trained?*

YesNo

Leash trained?*

YesNo

Good with children?*

YesNoDon't know

Good with cats?*

YesNoDon't know

Good with other dogs?*

YesNoDon't know

List other household pets*

Has this dog ever bitten while living with you?*

YesNo

Circumstances if "yes" to bitten*

Why are you seeking to relinquish this dog?*

Veterinary Information

Veterinarian

Address

Street Address

Street Address Line 2

CityState

Postal / Zip CodeCountry

Is this dog current on all vaccinations, including Rabies

YesNo

List all medications this dog is currently taking. Include Heartworm, Flea and Tick Medications, etc.*

List any known medical issues*

List any known behavioral issues or sensitivities (ex: separation anxiety, doesn't like baths, chews, etc.) that would be good for new owners to know

My signature certifies that:

I am 21 years of age or older;

I am the legal owner of the dog referenced in this application;

I release and indemnify Dachshund Rescue of Ohio from any responsibility for any false information provided in this application;

if accepted, I surrender and relinquish all legal ownership and future claims on the dog referenced in this application.

Type name. This will serve as your signature.

Type today's date

E-mail