Surrender Form

Owner's Name *

Address *

Home Phone *
Cell Phone *
Email *
Referred By *





If this Dog is a stray, how long has it been in your possession? *

Dog's Formal Name *

Sex of Dog *
MaleFemale
Breed *
Color *
Weight *
Spayed/Neutered? *
YesNo
Age of Dog *




Age of Dog at Purchase or Adoption *

Where was the Dog adopted or purchased? Please include name, state and phone number. *



THE MORE WE KNOW ABOUT YOUR DOG, THE BETTER JOB WE CAN DO OF FINDING THE BEST POSSIBLE HOME FOR IT. PLEASE ANSWER THE FOLLOWING QUESTIONS AS COMPLETELY AND HONESTLY AS POSSIBLE.

DOES YOUR DOG LIKE: *

Cats Does notToleratesLikesLoves
Children Does notToleratesLikesLoves



Is your Dog *

Can you leave him/her unattended in the house for long periods of time without him/her damaging anything? *
YesNoDon't know



Do you have a local veterinarian? *
YesNo

Name *
Phone *

Address *


Is the dog currently on Heartworm preventative? *
YesNo

Dog food brand *

Describe the Dog’s general temperament? *



I AM SURRENDERING MY DOG TO iHeart Animal Rescue AND WISH iHeart Animal Rescue PLACE MY DOG AND BY MY SIGNATURE CERTIFY I AM THE LEGAL OWNER OF THE ABOVE DOG AND THE ABOVE INFORMATION IS TRUTHFUL, CORRECT AND COMPLETE. I CERTIFY THE DOG HAS NEVER BITTEN OR BEEN AGGRESSIVE TOWARDS A HUMAN. I UNDERSTAND ANY ATTEMPTS TO MISLEAD OR FALSIFY INFORMATION WILL RESULT IN MY DOG EITHER BEING DENIED ACCEPTANCE INTO iHeart Animal Rescue OR BEING DESTROYED. SURRENDER FEE: $50 PAYABLE TO iHeart Animal Rescue



Dog's Name

Signature

Date