First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Cell Phone*

MUST ANSWER ALL OF THESE! Name of animal: Breed: Color: Age:*

Provide details explaining why you are requesting to surrender the dog. Being too vague will result in delay or denial.*

This dog was acquired from: *

What brand of food are you currently feeding your dog.*

Is your dog neutered or spayed?*

Are the dog's vaccinations current? If so, do you have documentation?*

Is dog(s) current on yearly heartworm test? The results?*

What type of heartworm preventative do you currently use?*

Is the dog suffering from any illness or injury? If so what?*

Please provide your veterinarian's name and telephone number.*

Is the dog kept inside or outside? Explain*

Is dog house broken?

Is the dog kennel trained?

Has dog had any obedience training? If so, where?

What is dog's current environment. i.e. Lives with dogs, cats, kids, *

Is dog aggressive to 1. male dogs 2. female dogs 3. all dogs?*

Has the dog ever displayed aggression towards any person? If so: was it a young child, older child, or adult? Please provide the extent of the injury and what occurred directly before the bite.*

Does dog have any behavioral problems? If so, please explain.*

Have you contacted any other Rescue trying to intake this dog. Or are you also trying to rehome this dog as you are contacting us?*

I, the Requestor, have provided complete and accurate information regarding the dog(s) to be surrendered to the SASPCA. I understand that once surrendered, I have transferred ownership of the dog(s) and have severed all ties to the dog(s). The only exception is if I provided incomplete and/or inaccurate information that leads to injury of anyone or anything. I will then be held legally liable to the parties impacted. *

Electronic Signature: *

Date: