Owner Surrender Form Owner InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Email* Dog General InformationDog's Name*Dog's Breed*Date of Birth or Age*Sex*-- select one --MaleFemaieColor*Weight*Dog Medical InformationSpayed/Neutered*-- select one --YesNoUp to Date on Rabies Shot*-- select one --YesNoUp to Date on Distemper Shot (DHLPP)*-- select one --YesNoUp to Date on Bordetella (Kennel Cough)*-- select one --YesNoHeartworm Tested within Last Year?*-- select one --YesNoHeartworm Preventative Last Season?*-- select one --YesNoMicrochipped?*-- select one --YesNoMicrochiped Number*Dog have any current medical problems?*-- select one --YesNoIf "Yes", please provide details:*The Name, Address, and Phone Number of Your Veternarian*Dog Personality InformationHow would you describe your dog's energy level?*-- select one --Low Energy/Couch PotatoModerate Activity LevelHigh EnergyWhat training has your dog had? (check any that apply)* None Some Obedience Housebroken Crate Trained What behavioral issues does your dog have? (check any that apply)* Digger Barker Separation Anxiety Fence Jumper Bolter Shy/Insecure Other If "Other", please explain*What is the height and type of your current fencing?*Is your dog good with? (check any that apply)* Large Dogs Small Dogs Children under 4 years old Children 4 years old and older Cats None Do you have other dogs in your home now?*-- select one --YesNoAny children in your home now?*-- select one --YesNoIf "Yes", provide ages of children:*Where does you dog stay during the day?*How many hours along per day?*Where does you dog sleep at night?*What brand/type of food do you feed your dog?*How much do you feed and how often?*Has your dog ever bitten a person?*-- select one --YesNoIf "Yes", please describe what happen in detail:*Has your dog ever bitten another animal?*-- select one --YesNoIf "Yes", please describe what happen in detail:*Why are you considering giving up your dog?*Please list other concerns or issues not addressed in the formWe will ask you additional questions and for clarification on the above questions, but this information will get us started. We will contact you to discuss the possibility of your dog coming into our rescue.