Your First Name :

Your Last Name :

Street Address :

Street Address 2 :

City :

State :

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Zip Code :

Your Email :

Phone :

Dog's Name :

Approximate age or exact birth date if known :

Gender :

MaleFemale

Is your dog spayed/neutered?

YesNo

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?

YesNo

If yes, please provide license number and issuing city

Has a complaint ever been filed with animal services regarding this dog?

YesNo

*If yes, please provide details:

Does your dog have any medical/health issues?

YesNo

*If yes, please provide details:

Is this dog current on vaccinations?

YesNo

Please provide the name and phone number of your veterinarian:

Has your dog nipped, mouthed, bruised or scratched with its teeth?

YesNo

*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?

YesNo

Does your dog chew when left alone?

YesNo

Does your dog have experience with other dogs, cats and/or children?

YesNo

*If yes, please provide ages and your dogs behavior with the children.