Release of Ownership Form

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NAME *

ADDRESS *

CITY *

STATE *

ZIP CODE *

PHONE NUMBER *

EMAIL ADDRESS *

REASON FOR NEEDING TO SURRENDER THE DOG: *

NAME OF DOG

BREED *

SEX

MALE

FEMALE

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ALTERED?

YES

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IF ALTERED, WHEN?

YYYY

DATE OF BIRTH

HOW DID YOU BECOME IN POSSESSION OF THE DOG? HOW LONG HAVE YOU HAD IT? *

IS THE DOG CURRENT ON ITS VACCINATIONS?

YES

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HAS IT BEEN SPAYED/NEUTERED?

YES

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IS THE DOG MICROCHIPPED?

YES

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WHAT IS THE MICROCHIP'S BRAND AND NUMBER?

DOES THE DOG HAVE ANY SPECIAL HEALTH NEEDS? IS IT ON ANY MEDICATIONS?

IS THE DOG CURRENTLY ON HEARTWORM PREVENTATIVE?

YES

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DO YOU HAVE VET RECORDS TO SUPPLY US FOR THE DOG? *

YES

Other:

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