Surrender Form

Owner's Name *

Address *

Home Phone *
Cell Phone *
Email *
Referred By *





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

Pet's Formal Name *

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




Age of Pet at Purchase or Adoption *

Where was the Pet 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 PET LIKE: *

Dogs Does notToleratesLikesLoves
Cats Does notToleratesLikesLoves
Children Does notToleratesLikesLoves



Is your Pet *

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 pet currently on Heartworm preventative? *
YesNo

Pet food brand *

Describe the Pet’s general temperament? *



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



Pet's Name

Signature

Date