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Sample Owner Surrender form

Discussion in 'Rescue & Adoption' started by maryellen, Sep 13, 2007.

  1. maryellen

    maryellen Good Dog

    Owner Surrender Application

    Please complete this application in full. Incomplete applications will not be processed __________________________________ is under no obligation to accept any animal into its care.

    Current Owner Information:

    Name: ________________________________________________________________________
    Address: ______________________________________________________________________
    City: _____________________State: _____________________ Zip Code: _________________
    Phone Number: ______________ Alt. Phone: ___________ Will you accept a collect call? ____
    Best time to call? _________________ E-mail Address: ________________________________
    How did you hear about ___________________(Shelter / Rescue Name)

    Identifying Information:
    Name: __________________________________ AKC Registration: _____________
    Name and contact information for the breeder: ________________________________
    Date of Birth: ____________ Sex: ___________ Spayed/Neutered? ___________________
    Tail Docked? _____________ Tattooed / Microchipped? ____________________________

    Health Profile: (medical records must be provided before surrender)
    Veterinarian and contact information: _______________________________________________
    Name of client your dog is listed under at vet: _________________________________________
    Is your dog currently vaccinated? __________Date of last veterinary appointment:____________
    Date of last heartworm test: ___________ Which brand of heart worm preventative is your dog currently taking? _____________________ Date of last dose: ____________________________
    Date of last Lyme Dz test: ______________ Is your dog vaccinated against Lyme Dz?_________
    List any major medical conditions or surgeries your dog has ever had: ______________________
    Personality Profile: (please be as detailed as possible)
    Has your dog ever bitten, nipped, or snapped at a person? ________________________________
    Does your dog bark or growl aggressively at people or other animals? ______________________
    Is your dog shy or afraid of anything? _______________________________________________
    Describe your dogs temperament? __________________________________________________
    Has your dog lived with children? _______________ Ages? _____________________________
    Is your dog good with children? ____________________________________________________
    Has your dog lived with other animals? ______________ What kind? ______________________
    Is your dog good with cats and small animals? ________________________________________
    is your dog good with other dogs? __________________________________________________
    Has your dog ever fought with another dog or animal? __________________________________
    Is your dog crate trained? ______________ Housebroken? _______________________________
    Where does your dog stay when left alone? ___________________________________________
    Does your dog have any destruction habits? ___________________________________________
    Does your dog like car rides? ______________________________________________________
    What are some activities your dog likes? _____________________________________________
    What are some activities your dog dislikes? ___________________________________________
    Has your dog had any formal training? _______________________________________________
    Has your dog ever been protection trained? ___________________________________________
    Can you disturb dog while eating? _______ Sleeping? ________Playing with toys? ___________ Does your dog guard any persons or objects? _________________________________________
    Describe your dogs activity level? Very High, High, Medium, Low, Very Low
    What brand of food and what quantity does your dog eat? _______________________________
    What type of home would you feel would best suit your dog? ____________________________

    Character References: (please provide complete contract information for three different people who are personally familiar with your dogs character)
    Reference 1: ___________________________________________________________________
    Reference 2: ___________________________________________________________________
    Reference 3: ___________________________________________________________________
    Additional Comments?

    I certify that the information provided on this form is true and correct. I understand that providing this information, I am under no obligation to relinquish my dog to ________________________ nor is ______________________________ under any obligation to accept my dog.

    Signature of owner: _______________________________________ Date: _________________

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