| Owner Surrender / Relinquishment |
Dog Information
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Gender:
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Spayed/Neutered:
(If not, fee is $50 for males and
$75 for females, in addition to the standard fee of $100.)
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Call Name:
Breed (Please submit pictures
with application)
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Color:
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Tattoo and/or Microchip
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Lic./Rabies Tag:
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DOB:
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Age:
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Is dog housetrained?:
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Crate Trained?:
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Leash Broken?:
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Any other Trainig?:
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If yes; Please, describe training
and/or any known problems:
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Temperament?:
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Describe:
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fIs dog good w/children?:
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Ages?:
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Is dog good w/other dogs?:
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Is dog good w/cats?:
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Describe any known problems
w/kids, cats or dogs:
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Where was the dog acquired?:
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When?:
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Medical Information
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Date of last DHLP-P?:
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Rabies?:
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Other vaccine(s)?:
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Last Heartworn test?:
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Result?:
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Preventative given?:
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Last Given?:
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List any health problems:
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List current medications:
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Release Information
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Note: Feilds marked by * are required.
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Reason for surrendering dog?:
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I hereby certify that I am the legal owner of the above described dog.
I agree that I am relinquishing all present and future claim to said dog.
Surrender fee is $100.00, to help defray the housing,
feeding, training and evaluation expenses.
I further certify that the above dog has not bitten any person
in the past 30 days, or while in my possession, whichever period is longer.
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*Name:
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*Address Line 1:
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Address Line 2:"
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*City:
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*State:
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*Zip:
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*County:
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Email:
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*Phone #:
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Cell #:
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Best Time to Call:
(Please, specify am or pm)
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