Apply to Surrender a Dog

First Name*
Last Name*
eMail Address
eMail Address Confirm eMail Address
Street Address*
Suite or Unit Number
City*
State*
ZIP
Country
- Phone*
History
This field is hidden when viewing the form
Dog Default Status: Submitted
- 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)
Month
Day
Year
How Long Have You Had This Dog?
- How Was The Dog Obtained?
- 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?*
- Please Explain
- Please Explain The Behavior Issues
- Please Explain The Health Issues
- Please Explain Care Needed
- How Many Homes Has This Dog Had?
Veterinarian Information
Do You Have a Veterinarian?
- Yes
- No
Name of Clinic
Name of Vet
Street Address
Suite or Unit Number
City
State
ZIP
Phone

- Dog's Name*
- Dog's Registered Name (If Purebred)
- Dog's Registration Number (If Known)
- Primary Breed*
- Breed Name
- Secondary Breed
- Breed Name
- Primary Color
- Which Color?*
- Secondary Color
- Which Color?*
Gender*
- Male
- Female
Dog's Date of Birth (If Known)
Month
Day
Year
Weight
Energy Level*
- Good With Kids?*
- Good With Dogs?*
- Please Explain*
- Good With Cats?*
- Good With Small Animals?
Good With Livestock?
Is Dog Trained?
- Are There Any Special Needs?
  - Yes
  - No
- What Special Needs?
  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

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

Dog & People
- Is Dog A One Person Dog?
- Does Dog Like Men?
- Please Explain*
- Please Explain*
- Does Dog Like Women?
- Please Explain*
- Please Explain*
- Does Dog Prefer Men?
- Please Explain*
- Does Dog Prefer Women?
- Please Explain*
- Does Dog Jump On People?
Is Dog Friendly With Strangers?
Is Dog Good With Other Animals?
Is Dog Good With Kids?
Does Dog Like Kids Under 6?
Does Dog Like Kids 6-10?
Does Dog Like Kids Over 10?
Dog's Temperament
Select All That Apply
How Are Dog's Social Skills?
Select All That Apply
Training
Does Dog Know Basic Commands?*
Select All That Apply
Is Dog Obedience Trained?*
Is Dog House Trained?*
Is Dog Crate Trained?*
Is Dog Leash Trained?*
How Does Dog React on Walks?
Select All That Apply
Does Dog Know How To Use A Doggie Door?
Does Dog Have Occasional Accidents?
Does Dog Tear/Chew Furniture Or Carpet?
Can Dog Be Left Uncrated?
Does Dog Dig?
Does Dog Know How To Swim?
Does Dog Jump Fences?
Does Dog Escape?
Does Dog Ride Well In The Car?
Barking
- Does Dog Bark At Noises?
- Does Dog Bark At Someone At The Door?
- Does Dog Bark Excessively?
Fear & Agression
- Does Dog Exhibit Submissive Behavior?*
- Please Describe*
- Please Describe*
- Does Dog Exhibit Aggressive Behavior?*
- Please Describe*
- Please Describe*
- Does Dog Guard Food?*
- Please Describe*
- Please Describe*
- Does Dog Guard Other Resources (Toys, People, etc.)?*
- Please Describe*
- Please Describe*
- Is Dog Shy?*
- Please Describe*
- Please Describe*
- Is Dog Fearful Of Strange Noises/Storms?*
- Please Describe*
- Please Describe*
- Has Dog Ever Bitten Anyone?*
- Please Explain*
- Has Dog Otherwise Attacked Anyone?*
- Please Explain*
- Has Dog Attacked Another Animal (Dog, Cat or Other)?*
- Please Explain*
- Is there anything else you would like to let us know about the dog's disposition?*

Medical: MicroChip Information
- Is Dog MicroChipped
- Are you prepared to transfer registration to {RescueName} on or prior to the surrender of the dog?
  - Yes
  - No
- MicroChip Company (If Known)?
- Other Company
- MicroChip Number (If Known)?
- Does Dog Have a Tattoo?
- Please Upload Photo*
  Drop files here or
  
  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:*
  Month
  Day
  Year
- Expected Date*
  Month
  Day
  Year
- 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)*

History

Veterinarian Information

Eating

Sleeping

Grooming

Dog & People

Training

Barking

Fear & Agression

Medical: MicroChip Information

Medical: Medical Conditions

Medical: Status

Medical: Dental Conditions

Medical: Known Allergies

Medical: Medicines

Notes

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