Surrender Form

If there is no response to a question, enter N/A

Upon submission of this form, you will see the screen change to grey.  Scroll up to the middle of the form where you will see the result of your submission.

If the form was successfully submitted you will see a 'Thank You' message.
If you do not see a 'Thank You' message, the form is incomplete and you will need to provide the requested information and resubmit the application.

Co-Applicant Name
Phone Number
How many people are in your household?
Ages of Minor (<17) Children (Type N/A if none)
How far will you travel to get a dog?
Is there a time limit in your search?
Short Text
Address (Street, City, State, Zip)
Reason for surrender
Desired surrender date
Dog's name
Sex (M/F)
Dog's birthdate
Neutered (Y/N)
Housebroken (Y/N)
Crate trained (Y/N)
Any physical issues?
Veterinarian's name
Vet's phone number
Vet's address (Street, City, State, Zip)
Most recent innoculations (Date & Type)
Heartworm negative? (Y/N)
Which preventative has been used?
Behavior reaction to other dogs? (Y/N)
Behavior reaction to children? (Y/N and ages)
Behavior reaction to strangers? (Y/N)
Behavior reaction to cats? (Y/N)
Does your dog walk on lead? (Y/N)
Is your dog good alone in a fenced yard? (Y/N)
Is your dog good alone in the house? (Y/N)
What does your dog like best?
What does your dog like least?
What does your dog fear?
How does your dog act when fearful or unhappy?
Has your dog ever bitten a human? (Y/N)
If yes, describe in detail.
Where does your dog sleep?
Where does your dog spend the day?
Brand of dog food and how much is fed daily?
Has dog had obedience training and what commands does he/she know?
Special skills?
Bad habits?
Where did you get your dog?
Anything else you would like for us to know?