Owner Surrender Form ALL FIELDS ARE REQUIRED Your First Name : Your Last Name : Street Address : Street Address 2 : City : State : ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code : Your Email : Phone : Dog Information 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. 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. Check Here SPAM Filter Question Please answer the following question to confirm that this is not SPAM. What is 6+1?