Owner Surrender Application

Your first name *

Your last name *

Street Address/Apt *

City *

State *

Zip Code *

Email address *

Best number to reach you *

Please attach a clear picture of your dog here *

Dog's Name *

Breed *

Age *

Sex *

Coloring *

Weight *

Is your dog neutered/spayed? *

Is your dog microchipped? *

If yes, please enter microchip number here:

Where did you get your dog? *

How long have you had your dog? *

Why are you seeking placement with us? *

If surrendering for a behavioral reason, would you consider keeping your dog if the behavior could be corrected? *

Please enter the date that you must surrender by: *

Is this date flexible? *

Is your dog up to date with his/her vaccinations? (Rabies, Distemper, Bordatella, HW check, fecal) *

We have limited medical runs. Dogs that are up to date on Rabies/Distemper/Bordatella can be more quickly accepted as they can be placed in general population runs. If he/she is not already up to date, are you able to get your dog up to date prior to surrendering? *

If you have them, please attach a copy of your dog's vet records here. This will greatly expedite the surrender process.

Does your dog have any health issues? *

If yes, please explain:

Has your dog had any surgeries (besides spay/neuter)? *

Please list all medications/supplements your dog is on (including flea & heartworm prevention). If you dog is not on any medications, please type "N/A" *

Name of your dog's primary veterinarian *

How does your dog do at the vet? Does he/she require a muzzle?

Tell us about your dog's personality *

Is he/she comfortable with both men and women? *

Has this dog lived with children? *

If so, please specify ages

If no, has your dog met children and what was his/her reaction?

What were the ages of any children this dog has met?

Has this dog lived with other dogs? *

If so, please indicate age/size/gender of dogs lived with. How does he/she do with other dogs?

Has this dog lived with cats? *

If so, please indicate age/gender of cats lived with. How does he/she do with cats?

Has this dog lived with any other type of animal(s)? *

If so, please specify the species and how your dog did with them.

Does your dog travel well in a car? *

Please describe your dog's feeding regime - brand of food? How many feedings per day? Allowed table scraps? Dry or canned food? Any dislikes?

What is your dog's reaction if you approach him/her when he/she is eating? *

Is your dog housetrained? *

Is your dog crate trained? *

Do you leave your dog alone for any period of time? If so, how long for and do you have concerns about them being on their own?

Has the animal ever been destructive in the house? Please describe

Where does your dog typically sleep? *

Will your dog willingly/easily give up toys? *

Would you describe your animal as a gentle player or does he/she like "rough" play? Describe your animal's play activity, eg. favourite game, favourite toy, etc.

How does this dog react to grooming?

Does he/she pull on the lead? *

Does your animal return when called while off leash? *

Has your dog escaped your property 2 or more times in the last 6 months? *

What commands, if any, does your dog know? For example, sit or sit down; lie or lie down etc.

Has your dog ever inflicted a serious injury to a person (such as an attack or a bite requiring medical attention)? *

If yes, did the bite happen while breaking up a dog fight or while the dog was in severe pain?

Has your dog ever attacked another animal resulting in severe injury or death to that animal? *

If your dog has bitten a person/animal, please describe the incident here:

I understand that Animal Aid Society has the right to accept or deny my request to surrender. By submitting this application, I certify that I have answered all questions fully and accurately to the best of my knowledge. If Animal Aid Society accepts this dog and it discovered that incomplete/inaccurate information regarding the health/disposition of this dog was submitted on this form, I understand that Animal Aid Society may seek to recover damages they may suffer as a result. Please enter your initials here and sign below. *

Please sign here: