OWNER SURRENDER FORM

Please email the completed Surrender Form to scbrjulie@hotmail.com or fax to: 734-573-6450

YOUR NAME: 
STREET ADDRESS: 
CITY:     		            		 STATE:           	 	ZIP:
HOME PHONE: 
CELL PHONE: 
WORK PHONE: 
EMAIL:   

DOG’S NAME: 
IS THIS A PUREBRED BOXER?: 
 	(IF MIX, PICTURE NEEDS EMAILED TO scbrjulie@hotmail.com)
DATE OF BIRTH OR AGE:
SEX:  
COLOR:
EARS CROPPED OR NATURAL: 
TAIL DOCKED OR NATURAL:
WEIGHT: 
SPAYED/NEUTERED: 
UP TO DATE ON RABIES SHOT: 
UP TO DATE ON DISTEMPER SHOT(DHLPP): 
HEARTWORM TESTED WITHIN LAST YEAR: 
ON HEARTWORM PREVENTATIVE LAST SEASON:
DOG HAVE ANY CURRENT MEDICAL PROBLEMS?:
	IF YES, PLEASE PROVIDE DETAILS: ___________________________________________________
_______________________________________________________________________________________________
WHERE DID YOU GET YOUR DOG?:
WHEN DID YOU GET YOUR DOG?:
HOUSEBROKEN?: 
CRATE TRAINED?:
DIGGER?:
BARKER?:

GOOD WITH OTHER DOGS?:
	ANY OTHER DOGS IN YOUR HOME NOW?:
		IF YES, LIST BREED(S), SEX, AGE  & IF SPAYED/NEUTERED: ____________________
_____________________________________________________________________________________________

GOOD WITH CATS?: 
	ANY CATS IN YOUR HOME NOW?:

GOOD WITH KIDS UNDER 4 YEARS?: 
GOOD WITH KIDS OVER 4 YEARS?: 
ANY CHILDREN IN YOUR HOME NOW?:
	IF YES, PROVIDE AGES OF CHILDREN: 

EVER BITTEN A PERSON?: 
	IF YES, PLEASE DESCRIBE WHAT HAPPENED IN DETAIL: ______________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________



EVER BITTEN ANOTHER ANIMAL?:
	IF YES, PLEASE DESCRIBE WHAT HAPPENED IN DETAIL: ______________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

WHERE DOES YOUR DOG STAY DURING THE DAY?:
HOW MANY HOURS ALONE PER DAY?:
WHERE DOES YOUR DOG SLEEP AT NIGHT?:

WHAT BRAND/TYPE OF FOOD DO YOU FEED YOUR DOG?:
HOW MUCH DO YOU FEED AND HOW OFTEN?:

WHY ARE YOU CONSIDERING GIVING UP YOUR DOG?: _______________________________________
_________________________________________________________________________________________

ADDITIONAL INFO WE SHOULD KNOW ABOUT YOUR DOG?:  _________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________________________________________________________________

We will ask you additional questions and for clarification on the above questions, but this information will get us started.  We will contact you
to discuss the possibility of your dog coming into our rescue.