Animal Surrender Form

Miles To Freedom Animal Rescue

Maine Shelter License # F-1831
Animal Surrender Form
Please fill out this form to the best of your ability. Your answers will help us get to know the animal and give us background information. This will ensure that we are able to place the animal in a new home that is best matched with his/her personality and needs.
Receiving Organization Information

Miles To Freedom Animal Rescue - 169 Number Six Rd - Oxford, Maine - 04270 - (207)418-7986
I hereby represent and warrant each of the following: (a) that I am the rightful owner of the animal(s) that is the subject of this Owner Surrender Form, (b) that I have full and complete authority to convey, surrender and relinquish the animal(s), (c) that I am hereby willfully surrendering and releasing any and all of my property rights to the animal(s), (d) that no other person has a right of ownership or property to the animal(s), (e) that once I surrender the animal(s), the animal(s) may not be returned to me, and (f) that the animal(s) has not bitten any person in the last 10 days.
Your Full Name:*
Physical Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:*
Please enter a valid phone number.
Drivers License Issuing State:*
Drivers License Number:*
Your Date of Birth:*
Email:*
example@example.com
The species I am surrendering is a...*

DogCat
Animal Name:*
Animals Breed:*
Animals Age:*
Animals Gender:*
Is this animal spayed or neutered*

YesNo
Does this animal have a current Rabies Vaccination?*

YesNo
How long have you owned this animal:*
How did you originally aquire this animal:*
Please give a detailed description as to why you are surrendering this animal:*
Has this animal ever bit a person or another animal?*

YesNo
If yes, Please explain:
Does this animal have any known medical issues:*

YesNo
If Yes, Please describe all:
How does this animal respond to Dogs:*
How does this animal respond to children:*
How does this animal respond to strangers:*
How does this animal respond to smaller animals such as chickens, birds, bunnies, farm animals:*
Is this animal house/litter box trained?*

YesNo
If this is a dog, is it crate trained?*

YesNoNA
If this is a dog, has this animal had any formal obedience training?*

YesNoNA
Can this animal be trusted alone for extended periods of time?*

YesNoNA
Can this animal be trusted alone for extended periods of time?*

YesNoNA
Does this animal know any special commands or tricks, please describe: *
Does this animal have any of the following behavioral issues? Please explain each issue.(Please be honest, it will let us know what things we should work on with the animal before placement)*

Separation or other anxietyChewingExcessive BarkingInappropriate UrinatingBeggingChasing (cars, animals, people, etc)Protective/Guarding behaviors (over house, family or other)Jumping on PeopleBiting or Aggressiveness towards people, other animals,etcFear (loud noises, people, objects, or other)This animal has none of the above listed issues
If you selected any of the above, please explain in detail:
Who do you use for a Veterinary Practice?*
What is their address:*
What is their phone number?*
Have you called your vet to release information to us to process your Veterinary Check? ****PLEASE NOTE**** This must be done for us to move forward with accepting any animal!*

YesNo
Would it be okay if the new adopter of this animal wanted to make contact with you about this animal? **

YesNo
Please take some time and this space to tell us anything else you feel is important for us to know about this animal so we can successfully work on placing it in a new, more appropriate fitting home:*
Todays Date*

MonthDayYear
Date (Please note we will adjust this date at the time of Adoption to the finalized adoption date
AM/PM Option
Signature*

Clear
Should be Empty:

Miles To Freedom Animal Rescue

Animal Surrender Form

Receiving Organization Information