K9 Rescue Ltd.'s Surrender Form

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Surrender Form

Owner Release / Surrender Form * Date:______________________

Dog Information:

Male [ ] Female [ ] * Spayed/Neutered [ ] * (If not, fee is $50 for males and $75 for females)

Call Name:_______________________________ Breed:________________________________________

Color:___________________________ Tattoo and/or Microchip #______________________________

Lic./Rabies Tag # ________________________ DOB / Age:____________________

Is dog registered? Yes [ ] No [ ] *if yes, fill out info at bottom)

Is dog housetrained? Yes [ ] No [ ] Crate Trained? Yes [ ] No [ ] Leash Broken? Yes [ ] No [ ]

Any other Training? [ ] Describe training and/or any known problems:__________________________

_____________________ Temperament? Outgoing [ ] Shy [ ] Describe: ____________________________

Is dog good with children? Yes [ ] No [ ] Ages? ___________________ Other dogs? Yes [ ] No [ ]

Cats? Yes [ ] No [ ] * Describe any known problems with kids, cats or other dogs:_______________

________________________________________________________________________________________________

Where was this dog acquired?______________________________________ When?_____________________

Medical Information:

Date of Last DHLP-P? ________________ Rabies?___________ other vaccine(s)?____________________

Last Heartworm Test: ______________________ Result? Neg [ ] Positive [ ]

Preventative given? Yes [ ] No [ ] Brand:_______________________ Last given:____________________

List any health problems:_______________________________________________________________________

List current medications:______________________________________________________________________

Release Information:

Reason for surrendering dog? ___________________________________________________

Agent Accepting Dog:__________________________________________

I hereby certify that I am the legal owner of the above described dog and I agree to release the same to K9 Rescue Ltd.with the understanding that I am relinquishing all present and future claim to said dog. Surrender fee is $200.00, to help defray the housing, feeding, training and evaluation expenses.

I further certify that the above dog has not bitten any person in the past 30 days, or while in my possession, whichever period is longer.

By signing here, I hereby certify that I have honestly answered all of the above questions, to the best of my knowledge, and have read and completely understand the above release.

Signature: _____________________________________ Date:____________________

Printed Name:________________________________________

Address:______________________________________________

City:________________________ State:__________ Zip:____________________

Phone #:__________________________ email:___________________________________________________
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For Office Use Only:

Surrender Fee Paid * Date:_________________ Amount:___________

Method of Payment: Cash [ ] Check [ ] #_________________

Proof of Vaccination Received? Yes [ ] No [ ]

Fee for S/N Collected? Yes [ ] No [ ] -- Amount $_______________

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