First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Cell Phone*

What is your dog's name?*

What is the breed of the dog you'd like to surrender?*

What is the size of the dog?*
Choose one: Small Medium Large

How much does the dog weigh?*

How old is the dog?*

Is the dog male or female?*
Choose one: Male Female

Why are you unable to keep your dog? (Be specific)*

Is the dog spayed/neutered?*
Choose one: Yes No

Where and when did you get the dog?*

Describe this dog's temperament.*

Is this dog friendly with other dogs?*
Choose one: Yes No

Is this dog cat friendly?*
Choose one: Yes No

Is this dog up to date on vaccinations? (Please be prepared to show proof.)*
Choose one: Yes No

Has this dog ever bitten a child or an adult? (If yes, please describe circumstances).*

If this dog was found, please provide as many details as possible (location, date). If the dog was not found, state N/A.*

If this dog was found, what have you done to try to find owners? Rescue may not be able to take in the dog until these steps have been completed.

Does this dog have any medical issues?*

Does this dog have any behavioral issues?*

Describe the perfect home for him/her.*

By signing my name, I hereby certify that I am the rightful owner of the animal who is subject of this owner surrender form. I hereby surrender any and all property rights to the animal as of today. I certify that no other person has property rights to this animal. I understand that by surrendering my rights to the animal, the animal may be transferred into the custody of another rescue. I also hereby certify that all information provided on this form is accurate. I understand that failure to disclose any information may result in the dog being returned to me/or mandatory compensation to the rescue for injury sustained and/or medical/vetting bills accrued. I understand that once I relinquish the animal, the dog will not be able to be returned. I certify that I have read and understand the terms of this Owner Surrender Form. Please type your name.*