First and last name? *

Complete Address City, State and Zip *

Best phone number to reach you at? *

Work phone with area code? *

Dog name? *

Dog gender? *

Age of dog? *

Please check all that apply: *

Does the dog have any medical conditions? (treated or untreated) *

Can you hold onto the dog while a new home is found? *

When do you need a new home by? *

Why are you surrendering your dog? *

A surrender fee/donation is required. For dogs under 3 years, the fee is $100, for dogs between 3-7 the fee is $150 and the fee for dogs over the age of 7 is $250. This surrender fee may be waived if the dog is up to date on vaccinations, is spayed/neutered and on heart worm medication (proof of vaccination and spay certificate is required). By dating and typing my initials in the space below I certify that I am the owner of, or have authority to surrender to Shiba Rescue of New Jersey, the animal described above. If SRNJ accepts the dog into rescue, the undersigned relinquishes all rights of ownership and any right to information on the disposition of said animal. I also authorize the release of any veterinary records regarding the animal. I certify that to the best of my knowledge I have disclosed all information about the animal concerning health, behavior, history and anything else that may affect the safe placement of the animal in a new home, and that all statements made above are true and correct. *