Dog Surrender Form Your InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Email* Your Pet's InformationPet's Name*Is Dog microchipped?*Select OneYesNoDon't knowMicrochip Number*Breed*Gender*Select OneMaleFemaleAge/DOB*Where did you originally get the dog?*Select oneHenderson ShelterAnimal FoundationRescue groupPet StoreBreederFriendCraigslistOther ShelterIf rescue group, name of group and location:*If other, please explain:*Has dog had vaccines in the past year? If so, please check which apply:* Rabies Parvo/distemper Bordetella Other: and list If Other:*Is Dog spayed/neutered?*Select oneYesNoIf the dog is spayed or neutered, where did you have it done? Or was it already spayed and neutered, when you aquired the dog?*How long have you had this dog?*Pet has been:*Select onemainly indoorsmainly outdoorsalways outdoorsWhy are you seeking to rehome this dog?*Has the dog ever bitten anyone or other dogs?*Select oneyesnoIf yes, please explain in detail:Vet clinic name*Vet clinic phone*Any current or previous medical conditions?*On any special food or diet?*Describe the dog’s personality Pet does well with:* other dogs cats kids (list ages below) strangers horses chickens men women other (list) If other:*Kids' ages:*Upload up to 3 photos of the dog (optional) Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, Max. file size: 300 MB, Max. files: 3. jpg,jpeg.png,gif allowed
