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/Postal Code
Country
- Phone*
History
Hidden
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
Hidden
How Long Have You Had This Dog?
- How Was The Dog Obtained?
- Please Explain
- Hidden
  Breeder's Name (if Known)
- Hidden
  Have They Been Notified?
  - Yes
  - No
- Hidden
  Why Not?
- Hidden
  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*
- Hidden
  Dog's Registered Name (If Purebred)
- Hidden
  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
- Hidden
  Is Dog A One Person Dog?
- Hidden
  Does Dog Like Men?
- Hidden
  Please Explain*
- Hidden
  Please Explain*
- Hidden
  Does Dog Like Women?
- Hidden
  Please Explain*
- Hidden
  Please Explain*
- Hidden
  Does Dog Prefer Men?
- Hidden
  Please Explain*
- Hidden
  Does Dog Prefer Women?
- Hidden
  Please Explain*
- Hidden
  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
Hidden
Is Dog Obedience Trained?
Is Dog House Trained?
Hidden
Is Dog Crate Trained?
Hidden
Is Dog Leash Trained?
Hidden
How Does Dog React on Walks?
Select All That Apply
Hidden
Does Dog Know How To Use A Doggie Door?
Does Dog Have Occasional Accidents?
Hidden
Does Dog Tear/Chew Furniture Or Carpet?
Hidden
Can Dog Be Left Uncrated?
Hidden
Does Dog Dig?
Hidden
Does Dog Know How To Swim?
Hidden
Does Dog Jump Fences?
Hidden
Does Dog Escape?
Does Dog Ride Well In The Car?
Hidden
Barking
- Hidden
  Does Dog Bark At Noises?
- Hidden
  Does Dog Bark At Someone At The Door?
- Hidden
  Does Dog Bark Excessively?
Fear & Agression
- Hidden
  Does Dog Exhibit Submissive Behavior?
- Hidden
  Please Describe*
- Hidden
  Please Describe*
- Hidden
  Does Dog Exhibit Aggressive Behavior?
- Hidden
  Please Describe*
- Hidden
  Please Describe*
- Does Dog Guard Food?
- Please Describe*
- Please Describe*
- Does Dog Guard Other Resources (Toys, People, etc.)?
- Please Describe*
- Please Describe*
- Hidden
  Is Dog Shy?
- Hidden
  Please Describe*
- Hidden
  Please Describe*
- Hidden
  Is Dog Fearful Of Strange Noises/Storms?
- Hidden
  Please Describe*
- Hidden
  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
- Hidden
  Expected Date*
  Month
  Day
  Year
- Please Explain Why Not*
Hidden
Medical: Dental Conditions
Hidden
Add Current Dental Conditions (N Number)
Hidden
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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