Jersey Pits Rescue Inc. Surrender Application

Name:

First Name Last Name

Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email:

example@example.com

Phone Number:

Area Code Phone Number

Please list the NAME / AGE / WEIGHT / GENDER of pet:

Reason for surrender request:

How long have you had your pet for?

Where did you get your pet from?

Please check off all that apply. My dog is:

Crate Trained Housebroken Leash Trained Trained with basic commands Kid friendly Cat friendly Dog friendly Good in the car

Please describe your dog's personality using as many details as possible:

Would you consider your dog to be more:

Submissive Neutral Dominant

What are your pet's likes and dislikes?

Does your dog have any medical issues that you are aware of?

Yes No

If yes, please describe your dog's medical issues and how they are treated:

Is your dog spayed or neutered?

Yes No

Is your dog vaccinated?

Yes No

If yes, what vaccines does your dog have? Please include date of vaccination:

Does your pet currently live with children under the age of 18? Or has your dog ever lived with children?

Yes No

If yes, please list the ages of the children in the house. Please describe how your dog interacts with the children in the house:

Does your pet currently live with other dogs? Or has your dog ever lived with other dogs?

Yes No

If yes, please list the names, ages, genders and breeds of the other dogs. Please describe how your dog interacts with the other dogs in the house:

Does your pet currently live with cats? Or has your dog ever lived with cats?

Yes No

If yes, please describe how your dog interacts with the cats in the home:

Has your dog ever bitten another animal or person?

Yes No

If yes, please describe the nature and frequency of the bites:

Please describe how your dog reacts to new people entering your home:

Please describe how your dog reacts to other dogs while out on walks:

Has your dog ever growled or shown aggression towards anyone?

Yes No

If yes, please describe what causes your dog to growl at someone or behave aggressively? (example: taking away toy, touching food, etc)

Are you able to email photos of your dog to jerseypitsrescue@gmail.com? If yes, please do so immediately after submitting this form. Pictures with people, kids, and other animals are preferred.

Yes No