Date(MM/DD/YY):

Animal Identification

Name Of Dog:

Breed:

Gender:   MALE    FEMALE

Spayed/Neutered:   YES    NO

Color(s) of Dog:

Scars, Tattoos, or Injuries:

Medical Information

Name Of Veterinarian:

Name Of Animal Hospital:

City/town:

State:   Zip Code:

On Heartworm Preventative:   YES    NO

Current Rabies Vaccine:   YES    NO     Date Of Last Rabies:

Current DHLPP Vaccine:   YES    NO     Date Of Last DHLPP:

Current Bordetella Vaccine:   YES    NO     Date Of Last Bordetella:

Animal Care

Types or Brands of Dog Food:

How Often Fed:
   Once Daily
   Twice Daily
   Free Fed
   Other:

RELEASE OF OWNERSHIP

I agree and understand that I am giving up all rights of possession and ownership of this dog and that I will not be able to redeem said dog at any time nor will I be allowed to know the dog's whereabouts. I agree and understand that said dog is now "sole property" of rescue. I promise that the information that I am giving is accurate and that the rescue will not be held liable or chargeable for any false information or any misrepresentations that I may have submitted on this form. I further agree and understand that rescue will evaluate this dog to determine whether or not the dog being surrendered will be considered "adoptable". The rescuers cannot guarantee placement. I also sign this give up agreement honestly and state truthfully that this animal has never bitten any human being.

Surrendering Owner Information

Printed Name Of Previous Owner:

Signature Of Previous Owner:

Street Address:

City:

State:     Zip Code:

Phone Number with Area Code:

Driver’s License#:

Date of Birth: