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* Your Pet's InformationPet's Name* Microchip Number Breed* Gender*MaleFemaleAge/DOB* Where did you originally get the dog?*ShelterRescue GroupPet StoreBreederFriendOtherIf rescue group, name of group:* 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?*YesNoHow long have you had this dog?* Pet has been:*mainly indoorsmainly outdoorsalways outdoorsWhy are you seeking to rehome this dog?*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
