Owner Surrender Form

Name: *

Please list any additional comments

Good with *

Dogs

Cats

Children

None

Unsure

Spay/ Neuter *

Yes

Unsure

Address

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

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

Dog's age, breed and date of birth *

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

If no to any of these please explain

Trained *

Leash trained

Potty trained

Crate trained

None

Unsure

Email *

Check here to receive email updates

Current on vaccines *

Yes

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. *

Please list any current or past medications

Reason for surrendering *

Dog's Name: *

Additional comments

Medical issues (Please describe) *

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.

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

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

Microchip *

Yes

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