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Owner Surrender
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Surrender Form
Step 1 of 3
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Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Please list any other information about your pet that would be useful to our foster family and potential adoptive families.
Please list as much as you can, good or bad, we should know.
Alternative Phone
Email
*
Enter Email
Confirm Email
Upload Dog Picture
Drop files here or
Accepted file types: jpg, gif, png.
Pet's Name
*
Type of Pet
*
Coat Color
*
Pet's Age
*
Is the pet spayed/neutered?
Yes
no
Sex:
Male
Female
Is the pet good with children?
Yes
No
Breed
Breed/Purebred or mix
Good with Cats?
Yes
No
Good with Dogs?
Yes
No
Is the pet microchipped?
Yes
No
Has the pet ever had any obedience training?
Yes
No
Is the pet crate trained?
Yes
No
Is the pet currently taking any medication?
Yes
No
Does the animal get daily excerise?
Yes
No
Has the animal ever bitten a person or an animal?
Yes
No
Hast it bitten a person or animal in the last 10 days?
Yes
No
How many hours is the pet left alone during the day?
Where is the pet kept at night?
Where did you adopt/purchase the dog from? Include date.
Why are you giving up the pet? Please explain in the area below.
Please list any other information about your pet that would be useful to our foster family and potential adoptive families.
Please list as much as you can, good or bad, we should know.
Veterinarian Name
Veterinarian Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Vet Records
Drop files here or
Have you ever given up a pet in the past for any reason?
Yes
No
Have you ever had an animal put down (euthanized)?
Yes
No
Agreement and Signature
By signing below, I hereby certify that I am the rightful owner, keeper, custodian, caretaker, of the animal who is the subject of this Owner Surrender Form, hereinafter referred to as "the pet". I hereby surrender any and all property rights to the animal described above. I certify that no other person has the right of property to the animal. I also hereby certify that the animal has NOT bitten of scratched a human or another animal within the past 10 days. I understand that once I surrender the animal, the animal wll not be available to be returned. I further certify that I have read and understand the terms of the Owner Surrender Form.
Full Name
Date
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