Owner Surrender Request Form
First Name
*
Last Name
*
Street Address 1
*
Street Address 2
City
*
State
*
Zipcode
*
Phone Number
*
Email Adress
*
Name of Animal
*
Breed
*
Gender
*
Unknown
Male
Female
Age
*
Alteration State
*
Not Altered
Spayed
Neutered
Unknown
Weight
*
Why are you surrendering this animal?
*
How long have you had this dog?
*
Where did you get this dog?
*
Is this dog microchipped?
*
No
Yes
Unknown
If able please attach a picture of the dog
Has this dog bitten a human in the last 10 days?
*
No
Yes
Unknown
Is this animal currently up-to-date on vaccinations?
*
No
Yes
Unknown
Does this dog have any known medical issues?
*
No
Yes
If yes, please explain
Name and contact number of vet clinic you use
What type of food do you feed the dog?
Does this dog have any of the following behavioral issues? Please check all that apply and further explain in the area below.
*
Separation or other anxiety
Digging
Chewing
Chasing (cars, animals, people, etc.)
Biting
Inappropriate Urinating
Protective of house, family, etc.
Aggression
Excessive Barking
Begging
Jumping up
Fear of loud noises\objects
My dog has none of these issues
If you checked a box for any behavioral issue above, please explain:
How does this dog respond to other dogs?
*
How does this dog respond to cats?
*
How does this dog react to strangers?
*
How does this dog respond to children?
*
Has this dog ever killed or injured another animal?
*
No
Yes
If yes, please explain:
Is this dog house broken?
*
No
Yes
Unknown
Has this dog had any formal obedience training?
*
No
Yes
Unknown
Does this dog know any commands?
*
No
Yes
Unknown
If yes, please explain
Is this dog kennel trained?
*
No
Yes
Unknown
Can this dog be trusted home alone for long periods of time?
*
No
Yes
Unknown
Are you able to foster this animal until a home is found or have a friend or family member willing to foster the animal until a home is found? Please explain.
*
What is the last possible date you can keep the dog?
*
Please take some time to tell us anything else you would like us to know about this dog.
My signature below certifies that I am the owner of, or have the authority to surrender to Furever After Rescue, the animal described above. I certify that to the best of my knowledge I have disclosed all information about the animal concerning health, behavior, history, and anything else that may affect the safe placement of the animal in a new home, and that all statements made above are true and correct.By signing below I understand that should Furever After Rescue agree to take possession of my animal, Furever After Rescue shall have sole and exclusive legal right to make all outcome decisions and take all actions deemed appropriate, including return to owner, adoption or euthanasia. By signing below I further understand that should Furever After Rescue agreement to take possession of my animal, at no time in the future will Furever After Rescue communicate the outcome of the animal to me or any other party.
*
Clear
Today's date
*