Owner Surrender Form

Surrendered Animal

Animal Type Full Name Breed

Age Sex Altered

Breeder Registration #1 Registration #2

Adults Children aged 0-5

Children aged 6-10 Children over 10

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

Good with cats Good with other dogs Good with other cats Aggressive

Housebroken / Litter trained Vocal Digs / Scratches destructively Chews

General temperament

Reason for Release

Vaccination Dates

Rabies Shot Core Vaccine 1 Core Vaccine 2

Parasite / Preventative Information

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