Surrender Application

If you need to surrender a pet, please fill out this application.  If you have more than one pet, please fill out
a separate application for each.  If you do not have a printer, please write your answers on a piece of
paper.  Please include a photo of your pet with this application.

Your Name: _______________________________________________
Your Address: _________________________________________________________
Your Email: __________________________________________
Your Phone Number: (___)______________________

Your Pet's Name: ____________________________
What type of animal is this (dog, cat, etc): _____________________
Breed: ___________________________
  Purebred   /   Mixed breed
  If mixed, with what other breed(s): ___________________________________________
Color: ______________________________________________
Gender:     Male   /   Female
Is this pet spayed/neutered?   Yes   /   No
  If not, are you willing to help pay for this surgery?   Yes   /   No
Date of birth / Age: ___________________
How much does this pet weigh? __________________________
Is this pet current on vaccinations (rabies, bordatella, distemper, parvo, etc)?   Yes   /   No
  Will you provide proof of vaccinations, including rabies certificate?   Yes   /   No
  When did this pet receive his/her last vaccinations? _________________________
Has this pet been tested for FIV/feline leukemia, heartworms/lyme/ehrlichia, and/or brucellosis?  Yes / No
  If so, which tests were done? __________________________
  When were these tests done? ___________________________
  What were the results? _________________________________
  Can you provide proof of tests/results?   Yes   /   No
How long have you had this pet? __________________________
Where did you get this pet? ___________________________________________________
Why is this pet in need of a new home? _________________________________________________
Does this pet legally belong to you?   Yes   /   No
  Are you willing to sign a legally binding surrender statement relinquishing ownership rights?  Yes / No
How long are you willing/able to keep this pet while we look for a suitable foster/adoptive home? ________
Is this pet used to being inside or outside? _________________
Where does this pet sleep at night? ____________________________________________
Where does this pet stay while you're away (work, vacation, etc.)? ____________________________
What kind of food is this pet used to (brand/variety/flavor)? ____________________________________
  How often is this pet fed (free-feeding, am/pm feeding, etc.)? _______________________
  How much food is this pet used to eating per day? ______________________
Has this pet been around children?   Yes   /   No
  If yes, how did he/she act? __________________________________________________
  Does this pet need a home without children?   Yes   /   No
Has this pet been around cats?   Yes   /   No
  If yes, how did he/she act? __________________________________________________
  Does this pet need a home without cats?   Yes   /   No
Has this pet been around dogs?   Yes   /   No
  If yes, how did he/she act? __________________________________________________
  Does this pet need a home without dogs?   Yes   /   No
Has this pet been around farm animals (horses, chickens, etc)?   Yes   /   No
  If yes, how did he/she act? __________________________________________________
  Does this pet need a home without farm animals?   Yes   /   No
Has this pet been around small pets (rabbits, ferrets, etc)?   Yes   /   No
  If yes, how did he/she act? __________________________________________________
  Does this pet need a home without small pets?   Yes   /  No
Is this pet aggressive in any way (food / dominence / possession / etc)?   Yes   /   No
  If yes, please explain: ______________________________________________________
Does this pet have a history of biting?   Yes   /   No
  If yes, please explain: ______________________________________________________
Does this pet have a problem with digging, or other destructive behaviors?   Yes   /   No
  If yes, please explain: ______________________________________________________
Does this pet suffer from separation anxiety?   Yes   /   No
Does this pet climb or jump fences?   Yes   /   No
  If yes, how high does a fence need to be to contain this pet? _______________________
Is this pet:   Housebroken   /   Crate Trained   /   Paper/Pad Trained   /   Not Potty Trained
What tricks/commands does this pet know? ___________________________________________
Does this pet have any special needs and/or medical problems?   Yes   /   No
  If yes, please explain: ___________________________________________________________
Are you willing to pay a surrender fee to help with the expenses of this pet while in our care?   Yes / No
Is this pet being surrendered with anything (collar, leash, kennel, toys, registration papers, etc)?  Yes / No
Please specify what: _________________________________________________________________