Owner Surrender Form

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

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. *

Microchip *

Yes

Unsure

Please list any current or past medications

Reason for surrendering *

Name: *

Please list any additional comments

Good with *

Dogs

Cats

Children

None

Unsure

Spay/ Neuter *

Yes

Unsure

Dog's Name: *

Additional comments

Address

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

Medical issues (Please describe) *

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 *

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.

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

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

Trained *

Leash trained

Potty trained

Crate trained

None

Unsure

Email *

Check here to receive email updates

Current on vaccines *

Yes

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