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Owner Surrender Form

Contact Information

First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
-

Email*

Home Phone*

Work Phone
x

Cell Phone*

Alt Email

*=required

How did you hear about us: *

Dog's Name:*

Dog's Sex: *

Is this dog spayed or neutered?*

Dog's Age: (Indicate if approximate or actual age)*

What is the current weight of your dog (in pounds)*

Does the dog have AKC Papers?*

Does the dog have a microchip? Please list the vendor and chip number if known*

Dog's Description: Please describe the color and markings (white, white with grey, badger face etc.) *

Does the dog have double dew claws:*

Where did you obtain this dog?

Breeder	Saving Pyrs in Need (SPIN)
Other Rescue	Pet Store
Prior Owner	Shelter
Other

If you selected "Other" above, please indicate how you obtained the dog.*

If this dog is a stray, have you made any attempt to search for the owner? (Ex. put up posters, search for owner on Craig's list, notify local shelter, etc.) List any methods used. *

How much did the dog cost? (If applicable)*

Your reason(s) for surrendering the dog:*

We understand that no dog is perfect. Please answer the following questions as honestly and accurately as possible so that we may better help in placing this dog in the best possible environment. Incomplete forms will not be accepted

How long have you had the dog?

Is the dog a: *

Where does the dog spend the majority of its time?*

Where does the dog sleep?*

How is the dog contained?*

If the dog is contained by a fence, please indicate height and type of fence:*

Has the dog ever escaped or jumped a fence? (select all that apply)

Escaped through an open door	Jumped over a fence
Jumped through a glass window	Jumped through a screen window
Tunneled under a fence	None of the above

If the dog has jumped a fence, please indicate height of fence and type of fence (stockade, picket, wire, electric etc.) *

Will the dog come when called? (select all that apply)

In the house only	Inside and Outside
Not at alll	Sometimes

Is the dog crate trained?*

If the dog is crate trained, please indicate how often, how long, and the last time the dog used the crate*

Is the dog house trained?*

Will the dog walk quietly on a leash?*

Does the dog get along safely with cats? (select all that apply)

Yes	No
Chases cats inside the house	Chases cats outside
Ignores cats	Inside the house only
Sleeps with cats	Unsure

Does the dog get along safely with other dogs? (select all that apply)

Yes	No
Female dogs only	Large dogs only
Male dogs only	Small dogs only
Unsure

Does the dog get along safely with children? (select all that apply)

Yes	No
Children over 12	Children over 6
Children under 6	Lives with children now
Unsure

Does the dog get along safely with strangers? (select all that apply)

Yes - greets strangers with a tail wag	Yes - once they are introduced by me
Yes - will allow strangers to approach and pet/rub	No - reacts aggressively and lunges
No - growls	No - runs away
Unsure

When food or treats are present, does the dog (select all that apply)

Allows other dogs near their food	Allows other dogs within 6 feet of food
Allows people to take food away	Is aggressive if another dog approaches
Is aggressive if another dog is in the room	Will allow people to take treats/bones away
Will growl or snap if a person attempts to touch the food bowl	Will not allow people or other dogs to take treats/bones away
Will share their food and treats/bones with other dogs

What is the dog fed? Please indicate can or dry, brand (Purina ONE, Purina ProPlan, Alpo, whatever was left over from dinner etc.) and quantity and how often. *

Would you describe the dog as

Sedentary	Slightly Active
Moderately Active	Very Active

Is the dog destructive in the home (select all that apply)

Yes	No
Sometimes Destructive - when left alone for over 2 hours	Somewhat - will chew papers or tissue boxes
Very Destructive - Chews windows/doors/rugs etc.	Unsure

Does the dog become anxious when left alone?*

Please describe your dog's behavior when left alone (anxious if left in the home alone, anxious if tied outside and you leave, etc.) *

Is there any history of aggressive behavior toward people?*

If you answered yes, please describe the aggressive behavior*

Is there any history of aggressive behavior with other animals?*

If you answered yes, please describe the aggressive behavior and type of animal involved*

Please tell us everything you can about the dog's history, personality traits, training, quirks, etc. *

If you checked any of the above boxes, OR if your dog has a medical issue that is not listed, please explain*

Date of last DHLP vaccination and expiration date*

Date of Last Rabies Vaccination and Expiration Date*

Date of last Bordatella vaccination and expiration date*

Date of last Lyme Vaccination and expiration date. If you are updating vaccines prior to surrender, please DO NOT give the lyme vaccine. We do not recommend it for this breed*

Date of last HeartWorm test*

Date given and type of Heartworm Preventative (HeartGard, Ivermectin, Trifexis etc.)*

Date Flea/Tick preventative last applied and type (K9 Advantix, Trifexis, Frontline etc.)*

Date of Last fecal exam for worms and Date/Type of worming (if applicable)*

Do you currently own other dogs?*

If you have other dogs, please list: Breed, Age, Sex, and whether spayed or neutered *

Do you currently own other pets? (cats, guinea pigs, birds, etc.) If so, please indicate type of animal, age, sex, and if spayed or neutered *

Veterinarian Name, Address and Phone Number, if no vet reply N/A*

Number of people in your household?*

Ages of Children living in the household*

How long are you able to hold the dog you want to surrender? *

Will you help transport the dog?*

Please acknowledge and initial below:

The answers supplied are true to the best of my knowledge

I acknowledge & accept this statement

I disagree with this statement

Submission of this form is not a transfer of ownership nor a contract between SPIN & I. Submission of this form does not imply a guarantee that SPIN will accept my dog for re-homing

I acknowledge & accept this statement

I disagree with this statement

I understand that I must email a picture of my dog to Savingpyrsinneed@yahoo.com a photo for this application to be considered by SPIN. Please include your name and the name of the dog with any photo submissions

I acknowledge & accept this statement

I disagree with this statement

If SPIN agrees to accept your dog, a Transfer of Ownership from you to take possession of your dog for re-homing,

I will NOT supply AKC registration records as my dog is not AKC registered	I will NOT supply veterinary records for my dog as there are none
I will supply AKC registration records	I will supply veterinary records for my dog

As part of the evaluation for accepting your dog, we will contact your listed veterinarian. I hearby provide authorization to release veterinary information and medical records regarding my pets to representatives of Saving Pyrs In Need (SPIN). (please initial)*

By submission of this information, and my(our) initials in the following box, I(we) attest that I currently have ownership of this dog, have made a serious effort to find the owner of the dog if he/she is a stray and that the information provided on this application is true and accurate to the best of my(our) knowledge.*

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