Furry Friendzy | Animal Rescue Owner Surrender Form

Any questions with an * next to it are required. Please reply to all questions. If a question does Not apply to you then please put N/A in that space. You will also be requested to submit pictures of your dog, preferably a front and side view.

Personal Information

Name:*

Address:*

City:*

State:*

Zip:

E-Mail Address:*

Home Phone:*

Work Phone:*

Mobile Phone:*

Where is the dog located:

Rescued by ME personally and is staying with ME.
I own the dog and it is still with me at this time.
In a Shelter.
At an Animal Control facility

City:

State:

City:

State:

Other Person: (specify)
If you have more than one dog to surrender, than fill out one application for each dog, making sure your name and email address are on each application. If we have any further questions, we will contact you by phone or by email.

Information on the Dog

Please tell us why you want to surrender this dog. Please be specific.

Name of the dog:

Sex of the dog

Male
Female

Age of the dog:

Date of Birth if known:

Age is unknown, but approximately:

Is the dog Spayed or Neutered?

Yes
No

Does the dog have a tail?

Yes
No

Other Comments:

Please provide the following information to the best of your ability:

Dog General History

Where did you originally get/purchase/find the dog? Please be specific.

If you purchased the dog from a breeder, did you sign a contract giving the breeder right-of-first refusal?

Yes
No

Breeder's name:

Breeder's Phone Number:

Have you contacted the breeder?

Yes
No

Is this dog AKC registered?

Yes
No

Do you have the papers?

Yes
No

Do you have a pedigree on this dog?

Yes
No

Is the dog

an Inside Dog
an Outside Dog
Not Sure

Other Comments:

Medical History

If you are the present owner of this dog, please provide information about the dog's veterinarian:

Veterinarian's name:

Veterinarian's Phone Number:

If the dog has Not been spayed or neutered are you willing pay to have it done?

Yes
No

Has the dog been tested for heartworm?

Yes
No

If Yes, test was:

Positive
Negative

If the dog has not been tested for heartworm are you willing to have this done?

Yes
No

If the dog is heartworm positive are willing to pay for the heartworm treatment?

Yes
No

Is the dog currently on heartworm preventative medication?

Yes
No

If not, when was the last date that heartworm preventative was given?

Is this dog current with its vaccinations?

Yes
No

If not, are you willing to have the dog given all his vaccinations?

Yes
No

Please provide other details of known/suspected medical conditions of this dog.

Other Comments:

Behavior

Is the dog housebroken?

Yes
No
Not Sure

This dog:

Needs to be confined to his/her crate. Explain in box below.
Confined to a certain area of the house. Explain in box below.
Has run of the house. Explain:

Needs to be confined to his/her crate. Explain in box below.

Confined to a certain area of the house. Explain in box below.

Has run of the house. Explain in box below.

Will the dog allow you to examine its body without much trouble?

Yes
No

How does the dog behave around adults?

Other (specify):

Is the dog good around children?

Yes
No

Is that experience:

Good
Questionable

Has the dog ever bitten or snapped at anyone.

Yes
No

If Yes, please explain & please be specific.

Has the dog ever shown any aggression towards anyone or another animal?

Yes
No

If Yes, please explain & please be specific.

How does the dog behave at the vet?

Please explain & be specific.

Is the dog good and well socialized around:

Other Male Dogs

Yes
No
Not Sure

Please explain & be specific.

Other Female Dogs

Yes
No
Not Sure

Please explain & be specific.

Is the dog good and well socialized around other female dogs

Other Small Animals

Yes
No
Not Sure

Please explain & be specific.

Is the dog good and well socialized around other small animals

Small Dogs

Yes
No
Not Sure

Please explain & be specific.

Cats

Yes
No
Not Sure

Please explain & be specific.

Livestock (Cows, Horses, Pigs, Chickens, Ducks)

Yes
No
Not Sure

Please explain & be specific.

Is the dog good and well socialized around livestock (Cows, Horses, Pigs, Chickens, Ducks)

Do you feel the dog is overly possessive about his food/treats/toys?

Yes
No

Please tell us about other behavior issues this dog may have.

Other Comments:

Training

Please list any commands the dog has knowledge of.

When on a leash,

Do you walk the dog?
Or does the dog walk you?

Has the dog had formal obedience training?

Please explain.

Has the dog been Guard or Protection Trained?

Yes
No

Other Comments:

Are you able to foster this dog until a foster/adoptive home can be found?

Yes
No

How did you hear about Furry Friendzy?

We reserve the right to refuse acceptance of any animal. Acceptance is based on many criteria, one of which is space availability. If you are out of our area, we will pass on your surrender form to another rescue. I understand that the information contained in this form might be passed on to another rescue.

Yes
No

Space for additional comments:

Note: I certify that the information provided on this form is true & correct. I understand that a physical evaluation of the dog and a temperament test will be performed by an experienced rescue volunteer to ensure we feel the dog is rehomeable before we accept this dog into Furry Friendzy’s program. If during the evaluation process we find that information contained in this surrender form to be false, we retain the right to turn down acceptance of the dog you are surrendering.
I also understand that the following criteria must be met before Furry Friendzy will consider taking my animal as an owner surrender. I also understand that if I am not able to meet these prerequisites, my circumstances I have explained above will be taken into consideration by Furry Friendzy in determining the acceptance of my animal as an owner surrender.

Owner Name:*

Signature:*