OWNER SURRENDER FORM

Owner’s Name: ________________________________________________________________________

Street address: _________________________________________________________________________

City: ____________________________________State:___________Zip:__________________________

Home Phone: __________________Cell Phone: __________________Work Phone: _________________

E Mail Address: ________________________________________________________________________

Dog’s Name: ___________________________________  Is the Dog spayed/neutered?  ____Yes    ____No

Current Age: ______________Sex:____________DOB:___________Weight:______________

Color: __________________Unique markings: ___________________________________________________

When did you acquire this dog? ________________________________________________________________

Where did you acquire this dog? _______________________________________________________________

Name, address, and phone number of your veterinarian: ____________________________________________

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Is the dog AKC registered? ____Yes    ____No  Are registration papers available? ____Yes    ____No

Is the dog microchipped? ____Yes    ____No     If yes, Microchip No: __________________________

Date of last Bordetella vaccination:  _________________Last DHLPP vaccination: ______________

Last Lyme vaccination: _______________Last Rabies vaccination: __________________________

Last Heartworm test: _________________Last HW preventative pill: ________________________

Has the dog ever been treated for ear infections? ____Yes    ____No

Has the dog ever been treated for hot spots or skin problems? ____Yes    ____No

Describe any other health problems affecting this dog:_______________________________________________

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Describe the brand of dog food used, how many times the dog is fed daily, the amount fed, and the times of feeding:

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Where does the dog live during the day? ___________________________________________________________

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How long each day is the dog left alone (without humans)? ____________________________________________

If yes:

- Please list their name, age and species ___________________________________________________________

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Has the dog ever growled at or bitten anyone? ____Yes    ____No  If yes, please explain the circumstances.

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What does this dog like? ________________________________________________________________________

What does this dog dislike? ____________________________________________________________________

What are the dog’s best points? __________________________________________________________________

What are the dog’s worst points? _________________________________________________________________

List any other information that might be helpful for placement or for the new owners:

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Why are you giving this dog up? _________________________________________________________________

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TO BE COMPLETED BY THE RELINQUISHING OWNERS:  I (WE) certify that we own the above dog and that this dog has not shown any signs of aggression, or bitten anyone in the past fourteen (14) days and that the statements above are true and accurate. I (WE) agree to indemnify and hold harmless 4 PAWS SOCIETY by, from and against all claims, suits, damages, liabilities, and costs related to or in any manner connected with this dog.  We further acknowledge understanding that the dog becomes the Property of 4 PAWS SOCIETY, and that they may place the dog, spay/neuter, or euthanize it as they see fit.  We also give consent to release any and all Veterinarian records to 4 PAWS SOCIETY.

Owner’s Signature: ____________________________________________Date:_____________________________