Owner Surrender Form

Surrendered Dog:

Full Name Breed

Age Sex Altered

Breeder UKC# AKC#

Is dog good with adults? Is dog good with children aged 0-5?

Is dog good with children aged 6-10? Is dog good with children aged over 10?

Has dog ever bitten anyone? If so, explain in detail

Is dog good with cats? Is dog good with other dogs? Is dog aggressive?

Is dog housebroken? Is dog a barker? Does dog dig? Does dog chew?

General temperament

Reason For Release

Vaccination Dates

Rabies Shot DHLPP Bordetella

Heartworm

Last Test Test Type Result

On Preventative Brand

General Health

Name Email Home Phone Work Phone

Address City State

Zip Code Country

Surrendering Owner's Signature

Surrendering Owner's Name (printed)
Entered Above

(Entering your name is a legal signature.)

Date

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.