Owner Surrender Form

Please list any additional comments

Name:

Trained *

Leash trained

Potty trained

Crate trained

None

Unsure

Additional comments

Dog's Name: *

I hereby attest to the best of my knowledge, this dog has no known illnesses or life threatening diseases. (Initial below) *

Please be sure to answer every question and give as much information as possible, this will help us determine if we are able to assist and find the best foster situation for the dog.

Please fill out the following information to help us understand the dogs' current needs as well as helping us to ensure the dog is placed in a suitable home.

Reason for surrendering *

Address

Dog's age, breed and date of birth *

Upload Photo of dog

We were unable to upload your file. Please ensure your file is 10MB or smaller in size.

Name: *

I certify all information is correct and accurate to the best of my knowledge (sign and date) *

Phone *

I am here by relinquishing all rights of ownership of my dog by surrendering it to Pound Puppyz Rescue. In signing this form, I am stating that I am the rightful and sole owner to the dog listed below. By signing this form and having received endorsement by an official Pound puppyz representative, I acknowledge that I have surrendered all rights of ownership for said animal. Your name serves as an electronic signature. *

Microchip *

Yes

Unsure

Email *

Good with *

Dogs

Cats

Children

None

Unsure

Has the dog had any allergic reactions to food or medications? Please list any known allergies and reactions

Current on vaccines *

Yes

List vaccines and dates given (You will need to submit all vaccine documentation with dog) *

Medical issues (Please describe) *

If no to any of these please explain

Type your paragraph here.

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- Owner Surrender Form
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Spay/ Neuter *

Yes

Unsure

Owner Surrender

Please list any current or past medications

Thank you for contacting us! If needed, you will hear back within 48-72 hours.

Name:

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