Surrender Form

In order for us to take in your dog you MUST provide all medical records

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Email Address

Dog's Breed

Dog's Name

Dog's Age

Dog's Gender

Dog's Color

Is the dog spayed or neutered?

Do you have AKC registration papers on this dog?

Is this dog tatooed?

If Yes, Please Provide Tattoo Number,Registry Number, and Phone Number

Is this dog microchipped?

If Yes, Please provide Registry Number and Phone Number

Name,Address and Phone Number of Veterinarian

Is the dog current on vaccinations

Are you able to provide a complete medical record on this dog?

Has this dog ever bitten anyone?

If YES please explain

Is this dog house trained?

Is this dog good with children?

Is this dog good with other pets?

Is this dog had basic obedience training?

Why are you giving up this dog?

I agree and understand that I am giving up all rights of possession and ownership of the described dog. I agree and understand that this dog is now the sole property of LIL PAWS Rescue. I promise that the information I am giving is accurate, and that LIL' PAWS Rescue will not be held liable or chargeable for any false information or misrepresentations that I may have submitted on this form. I further agree and understand that LIL PAWS Rescue will do whatever is necessary for the safety and well-being of this dog.

Previous Owner's Signature

Drivers License Number

Date of Signature

Indicates Response Required