First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County*

Country

Email*

Home Phone*

Work Phone
x

Cell Phone*

Alt Email

Text/Pager Email

Name of animal being surrendered:*

What is the animal's date of birth? If not known, please provide approximate age.*

What is the animal's gender?*

Has the animal been spayed or neutered?*

Last known heat cycle, otherwise please enter N/A.*

What is your dog's current weight? *

Current on vaccinations?*

When are the next vaccinations due?*

Date of last heartworm test:*

Is the animal on heartworm preventative? If so, what was the date last given?*

Please provide the name of your vet/clinic/hospital and telephone number. Be sure to call the vet office granting an NBRAN coordinator permission to contact if needed. If no current vet, please enter N/A*

Reason for Surrender:*

Where did you obtain the dog? Please include their contact info so we can confirm there is no "return" requirement.*

Is the animal house trained?*

Is animal crate trained?*

Has the animal received any obedience training?*

Where does the animal sleep?*

What brand of food is the animal eating? When? How much?*

Animal prefers company of:
Choose all that apply: Men Women Children No preference Other companion animals

Is the animal gentle with children?*

Is the animal OK with other dogs?*

Is the animal OK with cats or other animals?*

Is the animal microchipped? If yes, please provide microchip provider and chip #.*

Does the animal jump or climb fences?*

Does the animal dig out under fences?*

Do you consider the animal an escape artist?*

Is the animal OK in yard w/o supervision for short periods of time? If so, how many hours?*

If the animal does get out, does s/he respond when called?*

How would you describe the animal's personality?*
Choose one: Dominant Submissive Well-adjusted and socialized

Does the animal bark or howl when left alone?*

Does the animal suffer from separation anxiety?*

Is the animal trustworthy when left alone in the house?*

Does the animal know their name? Also, please list any specific commands the animal knows.*

Please list any of the animal's health conditions or medications. Also, please describe the animal's personality and tell us anything that might help us with placement even those things you think might be negative.*

Have you observed any particular fears, e.g. thunderstorms or behavioral problems, that need to be addressed?*

What are this animal’s favorite things? Playing fetch, playing with and chewing on toys, going for walks, cuddling, playing with other companion animals, etc.?*

By signing and submitting this form, I/we relinquish all rights of ownership of the Brittany listed above, to National Brittany Rescue & Adoption Network, Inc., (NBRAN), and do hereby certify to the best of our knowledge, that this dog has never bitten anyone. 

Further, it is understood that NBRAN was contacted with the express purpose of releasing our rights of ownership.  NBRAN agrees to accept responsibility for the care of said dog until such time as s/he is placed in an appropriate, loving home with approved adopters.  It is also explicitly understood that if, on the advice of NBRAN’s veterinarian, said dog cannot be rehabilitated to a state of good health then s/he may be humanely euthanized at the sole discretion of NBRAN. 

I/we also certify that the following information provided is as accurate and true as possible. 

Your typed signature below serves as your signature*