Pulled From The Pits Surrender Form

Pulled From The Pits 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

Pulled From The Pits

17 Lower Road

Minot, Maine 04258

(207)740-8229
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.
SURRENDERING OWNER INFORMATION
Name: *

First Name Last Name
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number: *

Area Code Phone Number
Drivers License State & Number: *
Date of Birth: *
Email Address: *
example@example.com
The species of animal I am surrendering is a.... *

Dog Cat
Animal Name: *
Animals Breed: *
Animals Age: *
Animals Gender *
Is this animal spayed/neutered? *

Yes No
Is the animal micro chipped? *

Yes No
If yes,Who is microchip company:
What is microchip number:
How long have you owned this animal: *
Where did you get this animal? *
Please give a brief description as to why you are surrendering this animal: *
Has this animal bitten anyone in the last 10 days? *

Yes No
If yes, please explain:
Does this animal have any known medical issues: *

Yes No
If yes, please describe all:
What Vet do you use: *
Veterinarian Phone number: *
What type of food do you feed: *
Does this dog 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 dog) *

Separation or other anxiety Chewing Excessive Barking Digging Inappropriate Urinating Begging Chasing (cars, animals, people, etc) Protective of (house, family, etc) Jumping up Biting Aggression Fear (loud noises, objects, etc) This animal has none of these issues
Please explain any of the above issues you selected: *
How does this animal respond to cats: *
How does this animal respond to dogs: *
How does this animal respond to children: *
How does this animal respond to strangers: *
Has this animal ever killed or injured another animal? *

Yes No
If yes, please explain:
Is this animal house trained? *

Yes No
Is this animal crate trained? *

Yes No
Has this animal had any formal obedience training? *

Yes No
If yes, please explain:
Can this animal be trusted alone for an extended period of time? *

Yes No
Does this animal know any special commands or tricks, please describe: *
Would it be okay if the new adopter of this animal wanted to make contact with you about this animal? *

Yes No
Please take some time to tell us anything else about this animal that you feel is important for us to know:
Date *

Month Day Year
Date
Time *

: Hour Minutes AM/PM Option
Signature

Clear
Should be Empty: