Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone 1
*
(###)
###
####
Phone 2
(###)
###
####
Email
*
Best time to call:
*
Hour
Minute
Second
AM
PM
By what date must you surrender the dog?
*
Are you the sole legal owner of the dog?
*
Dog's Name
*
Dog's Age
*
Dog's Sex
*
Please Select One
*
Dog's Color
*
Dog's Weight
*
Where did you get this dog?
*
How long have you had him/her?
*
Is the dog purebred?
*
Do you have AKC or ASCA papers?
*
Is the dog microchipped?
*
If microchipped, what is the number?
Veterinarian Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Veterinarian Phone
(###)
###
####
Has the dog ever lived with other dogs?
*
Has the dog ever lived with cats?
*
Is this dog used to being home alone during the day?
*
If yes, how many hours on average?
Does the dog have separation anxiety?
*
If yes, how do you handle it?
How do you exercise the dog? How often?
*
What kind of food is the dog eating now?
*
How often is he/she fed?
*
At what time(s)?
*
Is the dog on any vitamins or supplements?
*
If yes, please list:
What is the dog's disposition?
*
Is the dog confident or shy?
Can you take food away?
*
Yes
No
Unknown
Can you take toys away?
*
Yes
No
Unknown
Can you take bones away?
*
Yes
No
Unknown
Does the dog dig?
*
Yes
No
Unknown
Does the dog chew?
*
Yes
No
Unknown
Does the dog escape from the yard or house?
*
Yes
No
Unknown
Does the dog run away?
*
Yes
No
Unknown
Does the dog jump over or climb fences?
*
Yes
No
Unknown
Does the dog jump on people?
*
Yes
No
Unknown
Does the dog steal food or items from the counters or tables?
*
Yes
No
Unknown
Does the dog swim?
*
Yes
No
Unknown
Does the dog ride well in cars?
*
Yes
No
Unknown
Is this an inside or outside dog?
*
Is the dog housebroken?
*
Yes
No
Unknown
Is the dog crate trained?
*
Yes
No
Unknown
Does the dog get along with other dogs?
*
Yes
No
Unknown
Does the dog get along with cats?
*
Yes
No
Unknown
Does the dog get along with other animals?
*
Yes
No
Unknown
Is this dog aggressive to other dogs?
*
Yes
No
Unknown
If yes, what did the dog do to make you think it didn't like the other dog?
Is the dog possessive over the food dish?
*
Yes
No
Unknown
Does the dog accept strangers?
*
Yes
No
Unknown
Does the dog accept men?
*
Yes
No
Unknown
Does the dog accept women?
*
Yes
No
Unknown
Does the dog like to chase bikes or cars?
*
Yes
No
Unknown
Does the dog get along with children?
*
Yes
No
Unknown
Has the dog ever lived with children?
*
Yes
No
Unknown
If yes, for how long?
What were the childrens’ ages?
How did the children treat the dog?
Is there anywhere the dog does not like to be touched?
*
Yes
No
Unknown
If yes, where?
Is the dog afraid of thunderstorms?
*
Yes
No
Unknown
If yes, what does this dog do during a thunderstorm?
Has the dog ever growled at a person?
*
Yes
No
Unknown
If yes, please describe the circumstances
Has the dog ever snapped at a person?
*
Yes
No
Unknown
If yes, please describe the circumstances
Has the dog ever bitten a person?
*
Yes
No
Unknown
If yes, please describe the circumstances
Has the dog ever growled at or bitten another animal such as a dog or cat?
*
Yes
No
Unknown
If yes, please describe the circumstances
Has the dog ever displayed any other signs of aggression?
*
Yes
No
Unknown
If yes, please describe:
Does the dog like to grab your arm or clothes (mouthy)?
*
Yes
No
Unknown
If yes, please explain:
What does the dog dislike?
*
What is the dog afraid of?
*
Has the dog been to obedience school?
*
Yes
No
Unknown
If yes, which obedience school?
Does the dog know any commands? Please list:
Please describe your training methods:
*
Have you ever disciplined this dog when he/she has done something wrong? Please describe:
*
Why are you giving up this dog? (Please be as detailed as possible)
*
What are the dog's bad points? Please be as honest as possible - we know he/she may not be perfect but the more we know about him/her, the better we are able to select a suitable foster home and then the very best permanent home for him/her:
*
What are the dog's good points? Again, the more we know about him/her the easier it is to find the perfect home for him/her.
*
Is there anything else that you would like us to know about the dog?
*
OWNER’S SURRENDER AGREEMENT
*
I understand that DASH will utilize the information contained in this form to assist in selecting an appropriate Foster Home and Adoptive Home. I understand that DASH will make every effort to find a loving home for my dog and grant my permission to contact all of the medical service providers named in the Owner Surrender Form and hereby grant permission for the release of all records and information in their possession.
I understand that DASH will have full ownership of the dog effective immediately upon surrender.
Microchip Number (if implanted)
Surrendering Owners Name
*
First Name
Last Name
Date
MM
DD
YYYY
CHECKING THIS BOX WILL ACT AS YOUR SIGNATURE AS THE OWNER SURRENDER THE ANIMAL.
*
