Name of animal:
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:
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.*
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: *