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Apply to Surrender a Dog

1Current Owner Information

2Dog Basics

3Routine

4Disposition

5Medical

6Authorization

First Name*
Last Name*
eMail Address
eMail Address Confirm eMail Address
Street Address*
Suite or Unit Number
City*
State*
Select State
ZIP
Country
United States
- Phone*
History
This field is hidden when viewing the form
Dog Default Status: Submitted
- Are you the legal owner of the dog?*
  - Yes
  - No
- Please Explain*
- Are you the only owner of the dog?*
  - Yes
  - No
- Please Provide Other Owner's Name:
- Other Owner's Phone #
When Did You Get The Dog? (approximate if necessary)
MM slash DD slash YYYY
How Long Have You Had This Dog?
Select Length of Time
- How Was The Dog Obtained?
  Select Method
- Please Explain
- Breeder's Name (if Known)
- Have They Been Notified?
  - Yes
  - No
- Why Not?
- Owner of Dog's Sire (If Known)
- Why Are You Giving Up The Dog?*
- Please Explain
- Please Explain The Behavior Issues
- Please Explain The Health Issues
- Please Explain Care Needed
- How Many Homes Has This Dog Had?
  Select Number
Veterinarian Information
Do You Have a Veterinarian?
- Yes
- No
Name of Clinic
Name of Vet
Street Address
Suite or Unit Number
City
State
ZIP
Phone

- Dog's Name*
- Dog's Registered Name (If Purebred)
- Dog's Registration Number (If Known)
- Primary Breed*
- Breed Name
- Secondary Breed
- Breed Name
- Primary Color
- Which Color?*
- Secondary Color
- Which Color?*
Gender*
- Male
- Female
Dog's Date of Birth (If Known)
MM slash DD slash YYYY
Weight
Energy Level*
- Good With Kids?*
- Good With Dogs?*
- Please Explain*
- Good With Cats?*
- Good With Small Animals?
Good With Livestock?
Is Dog Trained?
- Are There Any Special Needs?
  - Yes
  - No
- What Special Needs?
  Select All That Apply
Description of the Dog
Featured Image
Accepted file types: jpg, jpeg, png, gif.
750 Wide x 750 High in Pixels
Additional Photos of The Dog
Drop files here or

Accepted file types: jpg, gif, png, jpeg, Max. file size: 1 MB, Max. files: 3.
Upload Photos of the Dog (minimum of 3 - include one head shot, one full body) and 750 Wide x 750 High in Pixels

Eating
- How Often Is The Dog Fed?
- Does Dog Eat Wet Or Dry Food (Or Both)?
- What Type Of Wet Food Does The Dog Eat?*
- How Much Wet Food Does The Dog Eat?*
- What Type Of Dry Food Does The Dog Eat?*
- How Much Dry Food Does The Dog Eat?*
- What Type Of Wet Food Does The Dog Eat?*
- How Much Wet Food Does The Dog Eat?*
- What Type Of Dry Food Does The Dog Eat?*
- How Much Dry Food Does The Dog Eat?*
Is Dog A Good Eater?
Does Dog Steal Food From Table/Counters?
Sleeping
- Which Room Does Dog Normally Sleep In At Night?
  Select All That Apply
- Please Describe*
- What Does Dog Use For A Bed?
  Select All That Apply
- Please Describe*
- Is Dog Allowed On Furniture?
Grooming
How Often is Dog Bathed?
Does Dog Mind Baths/Grooming
Does Dog Mind Toenails Clipped
Does Dog Mind Ears Cleaned

Dog & People
- Is Dog A One Person Dog?
- Does Dog Like Men?
- Please Explain*
- Please Explain*
- Does Dog Like Women?
- Please Explain*
- Please Explain*
- Does Dog Prefer Men?
- Please Explain*
- Does Dog Prefer Women?
- Please Explain*
- Does Dog Jump On People?
Is Dog Friendly With Strangers?
Is Dog Good With Other Animals?
Is Dog Good With Kids?
Does Dog Like Kids Under 6?
Does Dog Like Kids 6-10?
Does Dog Like Kids Over 10?
Dog's Temperament
Select All That Apply
How Are Dog's Social Skills?
Select All That Apply
Training
Does Dog Know Basic Commands?
Select All That Apply
Is Dog Obedience Trained?
Is Dog House Trained?
Is Dog Crate Trained?
Is Dog Leash Trained?
How Does Dog React on Walks?
Select All That Apply
Does Dog Know How To Use A Doggie Door?
Does Dog Have Occasional Accidents?
Does Dog Tear/Chew Furniture Or Carpet?
Can Dog Be Left Uncrated?
Does Dog Dig?
Does Dog Know How To Swim?
Does Dog Jump Fences?
Does Dog Escape?
Does Dog Ride Well In The Car?
Barking
- Does Dog Bark At Noises?
- Does Dog Bark At Someone At The Door?
- Does Dog Bark Excessively?
Fear & Agression
- Does Dog Exhibit Submissive Behavior?
- Please Describe*
- Please Describe*
- Does Dog Exhibit Aggressive Behavior?
- Please Describe*
- Please Describe*
- Does Dog Guard Food?
- Please Describe*
- Please Describe*
- Does Dog Guard Other Resources (Toys, People, etc.)?
- Please Describe*
- Please Describe*
- Is Dog Shy?
- Please Describe*
- Please Describe*
- Is Dog Fearful Of Strange Noises/Storms?
- Please Describe*
- Please Describe*
- Has Dog Ever Bitten Anyone?
- Please Explain*
- Has Dog Otherwise Attacked Anyone?
- Please Explain*
- Has Dog Attacked Another Animal (Dog, Cat or Other)?
- Please Explain*
- Is there anything else you would like to let us know about the dog's disposition?

Medical: MicroChip Information
- Is Dog MicroChipped
- Are you prepared to transfer registration to {RescueName} on or prior to the surrender of the dog?
  - Yes
  - No
- MicroChip Company (If Known)?
- Other Company
- MicroChip Number (If Known)?
- Does Dog Have a Tattoo?
- Please Upload Photo*
  Drop files here or
  
  Accepted file types: jpg, gif, png, jpeg, Max. file size: 5 MB, Max. files: 3.
- Please Describe*
Medical: Medical Conditions
Add Current Medical Conditions (N Number)
Add Past Medical Conditions (N Number)
Medical: Status
- Is Dog Spayed Or Neutered?
  - Yes
  - No
- Date:*
  MM slash DD slash YYYY
- Expected Date*
  MM slash DD slash YYYY
- Please Explain Why Not*
Medical: Dental Conditions
Add Current Dental Conditions (N Number)
Add Past Dental Conditions (N Number)
Medical: Known Allergies
- Add Allergies (N Number)
Medical: Medicines
- Add Medications (N Number)

Notes
Is there anything else you would like to let us know?
In your opinion, what would be the best type of home situation for this dog?
Authorization: I hereby represent and warrant each of the following: (a) that I am the rightful owner/keeper/caretaker/custodian of the dog (b) that I have authority to convey, surrender and relinquish the dog, (c) that I am hereby willfully surrendering and releasing any and all of my property rights to the dog, (d) that no other person has a right of ownership or property to the dog, (e) that upon surrender the dog may not be returned to me. I have read and understand the terms of this Surrender From.*
- Yes
Signature
Phone
This field is for validation purposes and should be left unchanged.

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