First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Home Phone

Cell Phone*

Reason you need to surrender your dog?*

Dog's Name*

Dog's current age?*

What is your dog's breed?

Is your dog male or female?*

Has your dog been spayed/neutered?

What is the size and weight of the dog:*

Is the dog Micro-chipped?

Did you get this dog from Perfect Paws Pet Rescue?

How long have you owned this dog?*

Has your dog been kept current on rabies, distemper, heartworm and flea/tick preventative?*

Do you have copies of your dog's medical records?*

Name of your veterinarian*

Veterinarian's phone number*

Is your dog on any medications?*

Is your dog house trained?

What commands does your dog know?

Has your dog shown any signs of aggression and if so, to what situations?*

Has your dog ever bitten anyone?

Does your dog bark excessively?

Does your dog dig?

Does your dog chew?

Does your dog jump fences?

Has your dog been around children and if so, how is his/her reaction?*

How does your dog react to new people?*

Has your dog lived with other pets and have they gotten along?*

What type of food do you feed your dog and how much?*

Does your dog have a favorite toy and game?

Where does the dog sleep at night:*

Where is your dog kept when home alone?*

Additional Comments

Our organization averages $200 in expenses per animal to get them ready for adoption and we are funded strictly on donations. Are you willing to make a non-refundable donation towards our adoption program? *

I state that I/We are the sole owners of the above described dog and that no other parties have a legal interest in this dog. I relinquish all rights, interest, and ownership of above dog to Perfect Paws Pet Rescue and hereby relinquish all claims to said dog. I understand that this surrender is irrevocable and ownership of the dog is now relinquished to Perfect Paws Pet Rescue. I certify that to the best of my knowledge the above information provided is true and accurate, and the dog has not bitten any human or animal and there are no claims as such from this. I agree to hold Perfect Paws Pet Rescue, Inc., any and all persons directly or indirectly involved with the surrender and future adoption of this dog harmless and indemnify the preceding against any and all claims, actions, demands, or liability of any kind whatsoever arising as a result or in connection with the above described dog. I further understand and agree that I receive no money or other compensation as a result of this surrender. Any donation made to Perfect Paws Pet Rescue furthermore does not constitute a sale and will be used to benefit rescue activity.

Your electronic signature below serves as acknowledgement that all information provided is true, correct and complete. On the Internet an Electronic Signature carries the same legal weight as if you were signing your name to a printed document. To complete this form, please provide your electronic signature below by typing your name in the box*

Date of “signature”*