Surrender Application Owner InformationOwner's Name* First Last Home Phone*Work/Mobile PhoneEmail Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Dog InformationName of Dog Dog InformationAgeSexBreedWeightBirthdate MM slash DD slash YYYY Is this dog crate trained?YesNoIs this dog spayed/neutered?YesNoIs this dog licensed?YesNoDoes this dog have its AKC papers?YesNoHow long have you owned this dog? Where did you get this dog?BreederPet StoreShelterStrayOtherIf "Other", please explain briefly: Dog's breeder (if known): Does the breeder know that the dogs needs a new home?YesNoWhy are you surrendering this dog?Is this dog housebroken?YesNoHas the dog ever been neglected or abused?YesNoIs the dog friendly with?MenWomenChildrenStrangersOther DogsCatsEnter Y for Yes, N for No, and U for UnknownHas this dog lived with?ChildrenOther DogsCatsSmall AnimalsEnter Y for Yes, N for NoDoes the dog alarm bark?YesNoDo you consider the dog to be protective?YesNoIf "Yes", please explain briefly:Has the dog ever bitten anyone or shown other signs of aggression?YesNoIf "Yes", please explain briefly:Has the dog ever received obedience training?YesNoWhere was the dog primarily kept?IndoorsOutdoorsHow often and what kind of exercise does the dog get?What type and brand of food is the dog currently eating? Any food it cannot eat? Does the dog know the following commands? Sit Down Stay Heel Come Other Other Commands Known Is the dog currently under veterinary care?YesNoVeterinarian Being Used Veterinarian Phone NumberWhen did the dog last receive the following?Rabies (note if 1 or 3 year vaccination): DHLPP (distemper/parvo): Heartworm test (positive/negative): Bordetella (kennel cough): Lyme disease vaccination: Worming: Is the dog currently taking heartworm preventative?YesNoDate Last Heartworm Preventative Was Given MM slash DD slash YYYY What is being used for heartworm preventative? Is anything being used for flea control?YesNoDate Last Flea Control Treatment Was Given MM slash DD slash YYYY What is being used for flea control? Does the dog have any of the following? Heart Problems Respiratory Problems Skin Problems Digestive Problems Eye Problems Hip/Orthopedic Problems Allergies Diabetes Muscular Disease Dental Problems Cancer Deafness Seizures/Neurological Issues Other If "Other", please explain briefly:Please list/explain any other health issues:Are you aware of any other medical or behavioral problems that would be important to someone interested in adopting this dog?YesNoIf yes, please provide as much information as possible.Are you willing to allow the dog to remain with you until an appropriate home is found?YesNoPhoneThis field is for validation purposes and should be left unchanged. Δ
Surrender Application – Online Form