Dog Surrender Information

Dog Surrender Information

By completing this form you are giving MAAW a written consent to relinquish all rights to your animal. To ensure the best outcome for your pet please complete this form.

Owner Details:

Given Name: Surname:

Address:

Postcode:

Email: Phone:

Dog Details:

Dog name: Age:

Breed: Colour:

Sex: Male ☐ Female ☐

Desexed: Yes ☐ No ☐ Unsure ☐

Microchipped Yes ☐ No ☐ Unsure ☐

Are you the microchip owner: Yes / No

Microchip number:

Is your dog registered with the Council: Yes ☐ No ☐

How long have you had this dog?

Why are you surrendering this dog?

Behaviour and Lifestyle:

Where did you get your dog?

How old was the dog when you got him/her?

Does your dog live with other animals? Yes / No

If Yes, what animals?

Is your dog good with the following? (please circle)

Familiar people: Yes /No Unfamiliar people Yes No

Children: Yes /No Cats: Yes / No

Dogs Yes / No Being left alone: Yes / No

Thunderstorms Yes / No Travelling in cars Yes / No

Does your dog live: Indoors only / Outdoors / Both

Where does your dog spend mot of his/her time?

What does your dog do when you leave the house?

What does you dog do when left alone?

Where does your dog sleep at night?

How much time does your dog spend alone?

Is your dog house trained: Yes / No

Does your pet: Chew / Dog holes / Bark excessively / Escape / Growl

Has your dog had any training?

How active is your dog?

Is your dog afraid of anything?

What does your dog eat?

How playful is your dog? Very playful / Not very playful

How affectionate is your dog? Very affectionate / Not very affectionate

Is your dog outgoing and interactive? Yes / No

Is your dog shy, likes to be left alone? Yes / No

Does your dog chase prey? Yes / No

Does your dog like being patted and picked up? Yes / No

Has your dog ever bitten anyone, even when playing? Yes / No

If yes, how bad was the bite?

Does your pet have any past or present medical conditions? Please give details:

Is your pet currently on any medication?

Do you have any other information about your dog that might help us to find the best outcome for him/her?

Conditions:

I am the owner of the dog being surrendered by me and I declare that no any other person has a right to ownership of this dog.

I hereby surrender all rights and interest in this dog to Mt Alexander Animal Welfare Inc.

By signing below, I certify that the information I have provided is truthful and accurate to the best of my knowledge.

Name:

Signature: Date:

Signature of MAAW representative: