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Apply to Surrender a Dog
1
Current Owner Information
2
Dog Basics
3
Routine
4
Disposition
5
Medical
6
Authorization
First Name
*
Last Name
*
eMail Address
eMail Address
Confirm eMail Address
Street Address
*
Suite or Unit Number
City
*
State
*
Select State
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United States
Phone
*
History
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Dog Default Status: Submitted
-- select a Status --
Available
Recovery Room
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Over The Bridge
Submitted
Surrendered
Forever Foster
Left Rescue
Denied
Are you the legal owner of the dog?
*
Yes
No
Please Explain
*
Are you the only owner of the dog?
*
Yes
No
Please Provide Other Owner's Name:
Other Owner's Phone #
When Did You Get The Dog? (approximate if necessary)
MM slash DD slash YYYY
How Long Have You Had This Dog?
Select Length of Time
Under A Year
1
2
3
4
5
6
7
8
9
10+
How Was The Dog Obtained?
Select Method
Puppy of Current Dog
Shelter
Stray
Private Home
Breeder
Other
Please Explain
Breeder's Name (if Known)
Have They Been Notified?
Yes
No
Why Not?
Owner of Dog's Sire (If Known)
Why Are You Giving Up The Dog?
*
Select All That Apply
New Baby
Not Home Enough/Not Enough Time
Found As A Stray
Owner's Health Issues
Dog's Health Issues
New Home
Allergies
Moving & Cannot Take Dog
Behavior Issues
Cannot Afford Care
Other
Please Explain
Please Explain The Behavior Issues
Please Explain The Health Issues
Please Explain Care Needed
How Many Homes Has This Dog Had?
Select Number
1
2
3
4
5+
Veterinarian Information
Do You Have a Veterinarian?
Yes
No
Name of Clinic
Name of Vet
Street Address
Suite or Unit Number
City
State
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP
Phone
Dog's Name
*
Dog's Registered Name (If Purebred)
Dog's Registration Number (If Known)
Primary Breed
*
Select Breed
Poodle
Poodle - Miniature
Poodle - Standard
Poodle - Teacup
Poodle – Toy
Ausiedoodle
Ausiepoo
Bernadoodle
Cavapoo
Cockapoo
Goldendoodle
Havapoo
Labradoodle
Maltipoo
Shihpoo
Yorkiepoo
Dad Is the Milkman
Heinz 57
Mix
Mutt
Akbash
Akita Inu
Alaskan Malamute
American Blue Heeler
American Eskimo
Appenzell Mountain Dog
Australian Cattle
Australian Kelpie
Australian Shepherd
Azawakh
Basenji
Beagle
Beauceron
Bergamasco
Bernese Mountain Dog
Bichon Frisé
Black Mouth Cur
Blue Lacy
Boerboel
Borzoi
Bolognese
Bouvier des Flandres
Boxer
Briard
Brittany
Brussels Griffon
Bulldog
Bulldog - American
Bulldog - English
Bulldog - French
Canaan
Cane Corso
Carolina Dog
Catahoula Leopard Dog
Cattle Dog
Cheweenie
Chihuahua
Chinese Crested
Chinese Shar-Pei
Chinese Foo Dog
Chinook
Chow Chow
Cirneco dell’Etna
Collie
Collie - Bearded
Collie - Border
Collie - Rough
Collie - Smooth
Corgi
Corgi - Cardigan Welsh
Corgi - Pembroke Welsh
Coton de Tulear
Dachshund
Dachshund - Miniature
Dachshund - Wirehaired
Dalmatian
Dogo Argentino
Dogue de Bordeaux
Entlebucher Mountain Dog
Eskimo Dog
Feist
Fila Brasileiro
French Bordeaux
Great Dane
Great Pyrenees
Greater Swiss Mountain Dog
Hamiltonstovare
Harrier
Havachon
Havamalt
Havana Silk Dog
Havanese
Havashire
Havatzu
Havawart
Hound
Hound - Afghan Hound
Hound - American Coonhound
Hound - American Foxhound
Hound - Basset Hound
Hound - Black and Tan Coonhound
Hound - Bloodhound
Hound - Bluetick Coonhound
Hound - Coonhound
Hound - English Coonhound
Hound - English Foxhound
Hound - Finnish Lapphund
Hound - Foxhound
Hound - Galgo Spanish Greyhound
Hound - Greyhound
Hound - Ibizan
Hound - Irish Wolfhound
Hound - Italian Greyhound
Hound - Keeshond
Hound - Norwegian Buhund
Hound - Norwegian Elkhound
Hound - Norwegian Lundehund
Hound - Otterhound
Hound - Pharaoh Hound
Hound - Plott Hound
Hound - Redbone Coonhound
Hound - Saluki
Hound - Scottish Deerhound
Hound - Swedish Vallhund
Hound - Treeing Walker Coonhound
Husky
Husky - Siberian
Spinone Italiano
Japanese Chin
Jindo
Kai Dog
Karelian Bear Dog
Kishu
Klee Kai
Komondor
Kuvasz
Kyi Leo
Lancashire Heeler
Leonberger
Lhasa Apso
Lowchen
Malshi
Maltese
Maltipom
Mastiff
Mastiff - Bull
Mastiff - Neapolitan
Mastiff - Tibetan
McNab
Morkie
Mountain Cur
Mountain Dog
Munsterlander
Native Amer Indian Dog (NAID)
New Guinea Singing Dog
Newfoundland
Papillon
Pekingese
Peruvian Inca Orchid
Petit Basset Griffon Vendéen
Pinscher
Pinscher - Affenpinscher
Pinscher - Doberman
Pinscher - German
Pinscher - Miniature
Portuguese Podengo
Pointer
Pointer - English
Pointer - German Shorthaired
Pointer - German Wirehaired
Pointer - Wirehaired Pointing Griffon
Pomeranian
Presa Canario
Pequeno
Portuguese Water Dog
Pug
Puli
Pumi
Retriever
Retriever - Black Labrador
Retriever - Chesapeake Bay
Retriever - Chocolate Labrador
Retriever - Curly-Coated
Retriever - Flat Coated
Retriever - Golden
Retriever - Labrador
Retriever - Nova Scotia Duck Tolling
Retriever - Yellow Labrador
Rhodesian Ridgeback
Rottweiler
Saint Bernard
Samoyed
Sarplaninac
Schipperke
Schnauzer
Schnauzer - Giant
Schnauzer - Miniature
Schnauzer - Standard
Setter
Setter - English
Setter - Gordon
Setter - Irish
Shar-Pei
Sheepdog
Sheepdog - Belgian
Sheepdog - Caucasian (Ovtcharka)
Sheepdog - Icelandic
Sheepdog - Illyrian
Sheepdog - Maremma
Sheepdog - Old English
Sheepdog - Polish Lowland
Sheepdog - South Russian Ovtcharka
Sheepdog - Shetland
Shepherd
Shepherd - Anatolian Dog
Shepherd - Australian
Shepherd - Belgian Laekenois
Shepherd - Belgian Malinois
Shepherd - Belgian Tervuren
Shepherd - Dutch
Shepherd - English
Shepherd - German
Shepherd - Pyrenean
Shepherd - White German
Shiba Inu
Shih Tzu
Shorkie
Sloughi
Spaniel
Spaniel – American Cocker
Spaniel - American Water
Spaniel - Boykin
Spaniel - Brittany
Spaniel - Cavalier King Charles
Spaniel - Clumber
Spaniel – English Cocker
Spaniel - English Toy
Spaniel - Field
Spaniel - Irish Water
Spaniel - English Springer
Spaniel - Springer
Spaniel - Sussex
Spaniel - Welsh Springer
Spaniel - Tibetan
Spanish Water Dog
Spitz
Spitz - Finnish
Spitz - German
Terrier
Terrier - Airedale
Terrier - American Hairless
Terrier - American Pit Bull
Terrier - American Staffordshire
Terrier - Australian
Terrier - Bedlington
Terrier - Biewer
Terrier - Black Russian
Terrier - Boston
Terrier - Border
Terrier - Bull
Terrier - Cairn
Terrier - Cesky
Terrier - Dandie Dinmont
Terrier - Fox
Terrier - Glen of Imaal
Terrier - Irish
Terrier - Jack Russell
Terrier - Kerry Blue
Terrier - Lakeland
Terrier - Manchester
Terrier - Miniature Bull
Terrier - Norfolk
Terrier - Norwich
Terrier - Parson Russell
Terrier - Patterdale / Fell
Terrier - Rat
Terrier - Scottish
Terrier - Sealyham
Terrier - Smooth Fox
Terrier - Silky
Terrier - Skye
Terrier - Staffordshire Bull
Terrier - Tibetan
Terrier - Toy Fox
Terrier - Toy Manchester
Terrier - Welsh
Terrier - West Highland White (Westie)
Terrier - Soft Coated Wheaten
Terrier - Wire Fox
Terrier - Wirehaired
Terrier - Yorkshire (Yorkie)
Thai Ridgeback
Tosa Inu
Vizsla
Weimaraner
Whippet
Xoloitzcuintli
Sheepadoodle
Breed Name
Secondary Breed
Select Breed
Poodle
Poodle - Miniature
Poodle - Standard
Poodle - Teacup
Poodle – Toy
Ausiedoodle
Ausiepoo
Bernadoodle
Cavapoo
Cockapoo
Goldendoodle
Havapoo
Labradoodle
Maltipoo
Shihpoo
Yorkiepoo
Dad Is the Milkman
Heinz 57
Mix
Mutt
Akbash
Akita Inu
Alaskan Malamute
American Blue Heeler
American Eskimo
Appenzell Mountain Dog
Australian Cattle
Australian Kelpie
Australian Shepherd
Azawakh
Basenji
Beagle
Beauceron
Bergamasco
Bernese Mountain Dog
Bichon Frisé
Black Mouth Cur
Blue Lacy
Boerboel
Borzoi
Bolognese
Bouvier des Flandres
Boxer
Briard
Brittany
Brussels Griffon
Bulldog
Bulldog - American
Bulldog - English
Bulldog - French
Canaan
Cane Corso
Carolina Dog
Catahoula Leopard Dog
Cattle Dog
Cheweenie
Chihuahua
Chinese Crested
Chinese Shar-Pei
Chinese Foo Dog
Chinook
Chow Chow
Cirneco dell’Etna
Collie
Collie - Bearded
Collie - Border
Collie - Rough
Collie - Smooth
Corgi
Corgi - Cardigan Welsh
Corgi - Pembroke Welsh
Coton de Tulear
Dachshund
Dachshund - Miniature
Dachshund - Wirehaired
Dalmatian
Dogo Argentino
Dogue de Bordeaux
Entlebucher Mountain Dog
Eskimo Dog
Feist
Fila Brasileiro
French Bordeaux
Great Dane
Great Pyrenees
Greater Swiss Mountain Dog
Hamiltonstovare
Harrier
Havachon
Havamalt
Havana Silk Dog
Havanese
Havashire
Havatzu
Havawart
Hound
Hound - Afghan Hound
Hound - American Coonhound
Hound - American Foxhound
Hound - Basset Hound
Hound - Black and Tan Coonhound
Hound - Bloodhound
Hound - Bluetick Coonhound
Hound - Coonhound
Hound - English Coonhound
Hound - English Foxhound
Hound - Finnish Lapphund
Hound - Foxhound
Hound - Galgo Spanish Greyhound
Hound - Greyhound
Hound - Ibizan
Hound - Irish Wolfhound
Hound - Italian Greyhound
Hound - Keeshond
Hound - Norwegian Buhund
Hound - Norwegian Elkhound
Hound - Norwegian Lundehund
Hound - Otterhound
Hound - Pharaoh Hound
Hound - Plott Hound
Hound - Redbone Coonhound
Hound - Saluki
Hound - Scottish Deerhound
Hound - Swedish Vallhund
Hound - Treeing Walker Coonhound
Husky
Husky - Siberian
Spinone Italiano
Japanese Chin
Jindo
Kai Dog
Karelian Bear Dog
Kishu
Klee Kai
Komondor
Kuvasz
Kyi Leo
Lancashire Heeler
Leonberger
Lhasa Apso
Lowchen
Malshi
Maltese
Maltipom
Mastiff
Mastiff - Bull
Mastiff - Neapolitan
Mastiff - Tibetan
McNab
Morkie
Mountain Cur
Mountain Dog
Munsterlander
Native Amer Indian Dog (NAID)
New Guinea Singing Dog
Newfoundland
Papillon
Pekingese
Peruvian Inca Orchid
Petit Basset Griffon Vendéen
Pinscher
Pinscher - Affenpinscher
Pinscher - Doberman
Pinscher - German
Pinscher - Miniature
Portuguese Podengo
Pointer
Pointer - English
Pointer - German Shorthaired
Pointer - German Wirehaired
Pointer - Wirehaired Pointing Griffon
Pomeranian
Presa Canario
Pequeno
Portuguese Water Dog
Pug
Puli
Pumi
Retriever
Retriever - Black Labrador
Retriever - Chesapeake Bay
Retriever - Chocolate Labrador
Retriever - Curly-Coated
Retriever - Flat Coated
Retriever - Golden
Retriever - Labrador
Retriever - Nova Scotia Duck Tolling
Retriever - Yellow Labrador
Rhodesian Ridgeback
Rottweiler
Saint Bernard
Samoyed
Sarplaninac
Schipperke
Schnauzer
Schnauzer - Giant
Schnauzer - Miniature
Schnauzer - Standard
Setter
Setter - English
Setter - Gordon
Setter - Irish
Shar-Pei
Sheepdog
Sheepdog - Belgian
Sheepdog - Caucasian (Ovtcharka)
Sheepdog - Icelandic
Sheepdog - Illyrian
Sheepdog - Maremma
Sheepdog - Old English
Sheepdog - Polish Lowland
Sheepdog - South Russian Ovtcharka
Sheepdog - Shetland
Shepherd
Shepherd - Anatolian Dog
Shepherd - Australian
Shepherd - Belgian Laekenois
Shepherd - Belgian Malinois
Shepherd - Belgian Tervuren
Shepherd - Dutch
Shepherd - English
Shepherd - German
Shepherd - Pyrenean
Shepherd - White German
Shiba Inu
Shih Tzu
Shorkie
Sloughi
Spaniel
Spaniel – American Cocker
Spaniel - American Water
Spaniel - Boykin
Spaniel - Brittany
Spaniel - Cavalier King Charles
Spaniel - Clumber
Spaniel – English Cocker
Spaniel - English Toy
Spaniel - Field
Spaniel - Irish Water
Spaniel - English Springer
Spaniel - Springer
Spaniel - Sussex
Spaniel - Welsh Springer
Spaniel - Tibetan
Spanish Water Dog
Spitz
Spitz - Finnish
Spitz - German
Terrier
Terrier - Airedale
Terrier - American Hairless
Terrier - American Pit Bull
Terrier - American Staffordshire
Terrier - Australian
Terrier - Bedlington
Terrier - Biewer
Terrier - Black Russian
Terrier - Boston
Terrier - Border
Terrier - Bull
Terrier - Cairn
Terrier - Cesky
Terrier - Dandie Dinmont
Terrier - Fox
Terrier - Glen of Imaal
Terrier - Irish
Terrier - Jack Russell
Terrier - Kerry Blue
Terrier - Lakeland
Terrier - Manchester
Terrier - Miniature Bull
Terrier - Norfolk
Terrier - Norwich
Terrier - Parson Russell
Terrier - Patterdale / Fell
Terrier - Rat
Terrier - Scottish
Terrier - Sealyham
Terrier - Smooth Fox
Terrier - Silky
Terrier - Skye
Terrier - Staffordshire Bull
Terrier - Tibetan
Terrier - Toy Fox
Terrier - Toy Manchester
Terrier - Welsh
Terrier - West Highland White (Westie)
Terrier - Soft Coated Wheaten
Terrier - Wire Fox
Terrier - Wirehaired
Terrier - Yorkshire (Yorkie)
Thai Ridgeback
Tosa Inu
Vizsla
Weimaraner
Whippet
Xoloitzcuintli
Sheepadoodle
Breed Name
Primary Color
Select Color
Apricot
Black
Blue
Chocolate
Cream
Grey
Red
White
Buff
Beige
Chestnut
Fawn
Gold
Liver
Orange
Ruby
Rust
Silver
Tan
Wheaten
Yellow
Black and Tan
Black and White
Blue and Tan
Blue and White
Brown and Tan
Brown and White
Buff and White
Chocolate and Tan
Chocolate and White
Liver and Tan
Red and White
Silver and Cream
White and Cream
Blenheim
Brindle
Flecked Ticked or Spotted
Harlequin
Hairless
Merle-Blue
Merle-Red
Particolor
Roan
Sable
Saddle or Blanket
Tri Color
Tuxedo
Phantom
Which Color?
*
Secondary Color
Select Color
Apricot
Black
Blue
Chocolate
Cream
Grey
Red
White
Buff
Beige
Chestnut
Fawn
Gold
Liver
Orange
Ruby
Rust
Silver
Tan
Wheaten
Yellow
Black and Tan
Black and White
Blue and Tan
Blue and White
Brown and Tan
Brown and White
Buff and White
Chocolate and Tan
Chocolate and White
Liver and Tan
Red and White
Silver and Cream
White and Cream
Blenheim
Brindle
Flecked Ticked or Spotted
Harlequin
Hairless
Merle-Blue
Merle-Red
Particolor
Roan
Sable
Saddle or Blanket
Tri Color
Tuxedo
Phantom
Which Color?
*
Gender
*
Male
Female
Dog's Birthday (Estimate If Necessary)
MM slash DD slash YYYY
Weight
Select Weight
1 Pound
2 Pounds
3 Pounds
4 Pounds
5 Pounds
6 Pounds
7 Pounds
8 Pounds
9 Pounds
10 - 20 Pounds
21 - 30 Pounds
31 - 40 Pounds
41 - 50 Pounds
51 - 60 Pounds
61 - 70 Pounds
71 - 80 Pounds
81 - 90 Pounds
91 - 100 Pounds
Over 100 Pounds
Energy Level
*
Select Energy Level
Active and Playful
Affectionate
Couch Potato
Gentle and Friendly
Happy
High Energy
Intelligent
Playful & Inquisitive
Good With Kids?
*
Select Option
I Like All Kids
I Like Kids Over 6
I Like Kids Over 10
I Don't Like Kids
I Have Not Been Tested with Kids
Good With Dogs?
*
Select Option
I Like All Dogs
I Only Like Small Dogs
I Only Like Big Dogs
I Like Select Dogs
I Don't Like Dogs
I Have Not Been Tested with Dogs
Please Explain
*
Good With Cats?
*
Select Option
I Like All Cats
I Like Some Cats
I Don't Like Cats
I Have Not Been Tested with Cats
Good With Small Animals?
Select Option
I Like All Small Animals
I Like Some Small Animals
I Don't Like Small Animals
I Have Not Been Tested with Small Animals
Good With Livestock?
Select Option
I Am Good with Livestock
I Am Scared of Livestock
I Am Aggressive with Livestock
I Have Not Been Tested with Livestock
Is Dog Trained?
Select Option
I'm Trained
I'm Currently In Training
I'm Not Trained Yet
Are There Any Special Needs?
Yes
No
What Special Needs?
Blind
Deaf
Doesn't Walk Well
Medical Condition
Select All That Apply
Description of the Dog
Featured Image
Accepted file types: jpg, jpeg, png, gif.
750 Wide x 750 High in Pixels
Additional Photos of The Dog
Drop files here or
Select files
Accepted file types: jpg, gif, png, jpeg, Max. file size: 1 MB, Max. files: 3.
Upload Photos of the Dog (minimum of 3 - include one head shot, one full body) and 750 Wide x 750 High in Pixels
Eating
How Often Is The Dog Fed?
Select Option
Once (Morning)
Once (Afternoon)
Once (Evening)
Twice (Morning & Evening)
Does Dog Eat Wet Or Dry Food (Or Both)?
Select Option
Wet
Dry
Both
What Type Of Wet Food Does The Dog Eat?
*
How Much Wet Food Does The Dog Eat?
*
What Type Of Dry Food Does The Dog Eat?
*
How Much Dry Food Does The Dog Eat?
*
What Type Of Wet Food Does The Dog Eat?
*
How Much Wet Food Does The Dog Eat?
*
What Type Of Dry Food Does The Dog Eat?
*
How Much Dry Food Does The Dog Eat?
*
Is Dog A Good Eater?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Steal Food From Table/Counters?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Sleeping
Which Room Does Dog Normally Sleep In At Night?
Any Room He/She Wants
In Adult's Room
In Kid's Room
Family/Living Room or Den
Garage
Outside
Other
Select All That Apply
Please Describe
*
What Does Dog Use For A Bed?
Crate
Dog Bed
Human Bed
Sofa/Chair/Furniture
Other
Select All That Apply
Please Describe
*
Is Dog Allowed On Furniture?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Grooming
How Often is Dog Bathed?
Select Option
Weekly
Every Other Week
Monthly
Does Dog Mind Baths/Grooming
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Mind Toenails Clipped
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Mind Ears Cleaned
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Dog & People
Is Dog A One Person Dog?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Like Men?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Please Explain
*
Please Explain
*
Does Dog Like Women?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Please Explain
*
Please Explain
*
Does Dog Prefer Men?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Please Explain
*
Does Dog Prefer Women?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Please Explain
*
Does Dog Jump On People?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Is Dog Friendly With Strangers?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Is Dog Good With Other Animals?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Is Dog Good With Kids?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Like Kids Under 6?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Like Kids 6-10?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Like Kids Over 10?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Dog's Temperament
Friendly
Playful
Dominant
Fearful
Shy
Mellow
Active
Aggressive
Select All That Apply
How Are Dog's Social Skills?
Plays with Dogs
Has Selective Dog Friends
Plays at Doggie Daycare
Plays at Dog Beach
Select All That Apply
Training
Does Dog Know Basic Commands?
Sit
Stay
Down
Off
Heel
Come
Leave It
All Of The Above
None Of The Above
Select All That Apply
Is Dog Obedience Trained?
Select Option
Yes
No
In Training
Not Tested/Not Sure
Is Dog House Trained?
Select Option
Yes
No
In Training
Not Tested/Not Sure
Is Dog Crate Trained?
Select Option
Yes
No
In Training
Not Tested/Not Sure
Is Dog Leash Trained?
Select Option
Yes
No
In Training
Not Tested/Not Sure
How Does Dog React on Walks?
Well Mannered
Pulls on Leash
Likes Other Dogs
Happy to See People (Strangers)
OK with Distractions (Bikes, Skateboards)
Doesn't Likes Other Dogs
Lunges at Other Dogs
Isn't Happy to See People (Strangers)
Doesn't Like Distractions (Bikes, Skateboards)
Drags Walker
Select All That Apply
Does Dog Know How To Use A Doggie Door?
Select Option
Yes
No
In Training
Not Tested/Not Sure
Does Dog Have Occasional Accidents?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Tear/Chew Furniture Or Carpet?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Can Dog Be Left Uncrated?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Dig?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Know How To Swim?
Select Option
Yes, Loves It
Yes, Doesn't Like It
Some Or Sometimes
Not Tested/Not Sure
No
Does Dog Jump Fences?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Escape?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Ride Well In The Car?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Barking
Does Dog Bark At Noises?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Bark At Someone At The Door?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Does Dog Bark Excessively?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Fear & Agression
Does Dog Exhibit Submissive Behavior?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Please Describe
*
Please Describe
*
Does Dog Exhibit Aggressive Behavior?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Please Describe
*
Please Describe
*
Does Dog Guard Food?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Please Describe
*
Please Describe
*
Does Dog Guard Other Resources (Toys, People, etc.)?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Please Describe
*
Please Describe
*
Is Dog Shy?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Please Describe
*
Please Describe
*
Is Dog Fearful Of Strange Noises/Storms?
Select Option
Yes
No
Some Or Sometimes
Not Tested/Not Sure
Please Describe
*
Please Describe
*
Has Dog Ever Bitten Anyone?
Select Option
Yes
No
Unknown
Please Explain
*
Has Dog Otherwise Attacked Anyone?
Select Option
Yes
No
Unknown
Please Explain
*
Has Dog Attacked Another Animal (Dog, Cat or Other)?
Select Option
Yes
No
Unknown
Please Explain
*
Is there anything else you would like to let us know about the dog's disposition?
Medical: MicroChip Information
Is Dog MicroChipped
Select Option
Yes
No
Unknown
Are you prepared to transfer registration to {RescueName} on or prior to the surrender of the dog?
Yes
No
MicroChip Company (If Known)?
Select Company
24Pet Watch
AKC
AVID
Found Animals
Home Again
Nano
Pet Link
Smart Tase
Other
Other Company
MicroChip Number (If Known)?
Does Dog Have a Tattoo?
Select Option
Yes
No
Unknown
Please Upload Photo
*
Drop files here or
Select files
Accepted file types: jpg, gif, png, jpeg, Max. file size: 5 MB, Max. files: 3.
Please Describe
*
Medical: Medical Conditions
Add Current Medical Conditions (N Number)
Add Past Medical Conditions (N Number)
Medical: Status
Is Dog Spayed Or Neutered?
Yes
No
Date:
*
MM slash DD slash YYYY
Expected Date
*
MM slash DD slash YYYY
Please Explain Why Not
*
Medical: Dental Conditions
Add Current Dental Conditions (N Number)
Add Past Dental Conditions (N Number)
Medical: Known Allergies
Add Allergies (N Number)
Medical: Medicines
Add Medications (N Number)
Notes
Is there anything else you would like to let us know?
In your opinion, what would be the best type of home situation for this dog?
Authorization: I hereby represent and warrant each of the following: (a) that I am the rightful owner/keeper/caretaker/custodian of the dog (b) that I have authority to convey, surrender and relinquish the dog, (c) that I am hereby willfully surrendering and releasing any and all of my property rights to the dog, (d) that no other person has a right of ownership or property to the dog, (e) that upon surrender the dog may not be returned to me. I have read and understand the terms of this Surrender From.
*
Yes
Signature
Name
This field is for validation purposes and should be left unchanged.
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