Owner Surrender Form

ALL FIELDS ARE REQUIRED

Your First Name :
Your Last Name :
Street Address :
Street Address 2 :
City :
State :
Zip Code :
Your Email :
Phone :

Dog Information

Dog's Name :
Approximate age or exact birth date if known :
Gender :
 Male Female
Is your dog spayed/neutered?
 Yes No
Breed (Purebred, Mixed) :
How long have you had this dog?
Where did you get her/him?
Please tell us why you need to give up your dog :
Is your dog licensed?
 Yes No
If yes, please provide license number and issuing city
Has a complaint ever been filed with animal services regarding this dog?
 Yes No
*If yes, please provide details:
Does your dog have any medical/health issues?
 Yes No
*If yes, please provide details:
Is this dog current on vaccinations?
 Yes No
Please provide the name and phone number of your veterinarian:
Has your dog nipped, mouthed, bruised or scratched with its teeth?
 Yes No
*If yes, please provide details:
Where does your dog stay when you leave her/him alone at home?
Do you use, or have you ever used, a dog crate for this dog?
 Yes No
Does your dog chew when left alone?
 Yes No
Does your dog have experience with other dogs, cats and/or children?
 Yes No
*If yes, please provide ages and your dogs behavior with the children.

Thank you for completing the surrender profile. This certifies you are voluntarily surrendering your Shar Pei to Florida Shar-Pei Rescue and have no recourse in where she/he is fostered or adopted to. Florida Shar-Pei Rescue survives through donations made to our Rescue, and we would appreciate a donation to accept your surrender.

I understand that by filling out this form I am submitting my dog for consideration into the rescue and it is not a guarantee that FSPR will take my dog.

Please check this box to acknowledge above.
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