Dog Surrender Form

Personal Information

  • Name:
  • Address:
  • City, State, Zip:
  • Phone #: (indicate if home/work/cell, and include area code)
  • Best time to reach you:
  • E-mail address:

Dog's Information

  • Dog’s name:
  • Breed:
  • Male/female:
  • Age/DOB:
  • Spayed/neutered:
  • Color:
  • Weight:
  • Microchip Co.:
  • Microchip #

Surrender Information

  • Where did you get this dog?
  • How long have you had this dog?
  • Why are you surrendering this dog?

Health Information

  • When was the dog last vaccinated:
  • Date of rabies vaccination:
  • Have his/her teeth ever been cleaned?
  • If yes, when?
  • Date last tested for heartworm:
  • Brand of heartworm prevention:
  • Last taken:
  • Flea and tick treatment used:
  • Brand:
  • When last applied:
  • Is the dog on any medication?
  • Name and address of veterinarian:
  • Does the dog have any health problems such as ear infections, eye problems, luxating patellas (knees), renal problems, skin problems, other:
  • Has the dog ever had surgery?
    If yes, please explain.

Behavioral Information

  • How does the dog walk on leash?
  • Is the dog housebroken/paper trained?
  • Is the dog crate trained?
  • Has the dog ever bitten you, another person, a child, or other animal? (Answering yes to this question will not automatically mean that your dog will not be accepted. PMR needs to know all pertinent information so that the dog can be rehomed in a proper environment. Failure to disclose your dog's history of aggression could make you liable if someone is injured.)
  • If yes, please explain.
  • Has this dog ever been abused?
  • If yes, please explain.
  • Has the dog ever had any formal training?
  • If yes, please give details.
  • Does the dog know any commands or tricks?
  • If yes, please describe.
  • How does the dog react to the following:

Children:
Strangers:
Men:
Dogs:
Cats:
Being left alone:
Crate confinement:
Grooming:
Veterinarian:
Traveling in the car:

  • Does the dog do any of the following:

-Bark excessively:

-Chew/Damage property:

-Dig:

-Act aggressively (towards people, children, other animals, around food):

-Possessive of food, toys, treats:

-Bite:

General Information

  • Where does the dog stay when you are not home?
  • Where does the dog sleep?
  • What do you feed the dog?
  • When does the dog eat?
  • When does your dog go out?
  • Is there anything special that your dog likes?
  • Is there anything that your dog dislikes?
  • What does your dog fear?
  • Does your dog have any bad habits?
  • Does your dog have a favorite toy?

I certify that the above information is true and accurate to the best of my knowledge, and that I have not willfully concealed information about this dog. I certify that I am the legal owner of this dog and I hereby apply to surrender this dog to PMR for placement in a suitable home. I understand that if PMR accepts my dog I will relinquish all ownership rights and I will not be provided with personal information about the new owner, and that the new owner will not be provided with my personal information. If my dog is accepted by PMR I consent to make a donation to PMR. I understand that this donation is used to cover any expenses incurred by PMR in caring for my dog and preparing him/her for adoption, and is a voluntary contribution towards PMR’s charitable work of rescuing, rehabilitating, and rehoming dogs. I understand that submission of this application is not a guarantee of acceptance.

Name:
Date: