Owner Surrender Application

Owner Surrender

First name

Last name

Birthday

Month

Day

Year

Address

Phone

Email

Household Information

Please tell us about your household:

Do you rent or own your home?

Own

Rent

If you rent, please provide the landlords name and contact number.

Do you have a fenced yard?

Yes

No

Who lives in your household? (Ages, other pets, etc)

In everyone in agreement in your household to adopt/foster a pet?

Yes

No

Pet History and Preferences

Have you ever adopted from a rescue or shelter before?

Yes

No

If yes, tell us about your experience:

Please Specify

What breed or size of dog are you interested in?

Home Environment

Please describe the environment you will be providing for your new pet:

How many hours will the pet be left alone each day?

Where will the pet be kept during the day? (e.g., house, yard, kennel, etc.)

Where will the pet sleep at night?

Veterinary Care

Do you have a current veterinarian?

Yes

No

If yes, please provide the vet’s name and contact information:

Are you willing to provide ongoing medical care, including vaccinations, flea control, heartworm prevention and regular checkups? ( ONLY FOR ADOPTERS – FOSTER VETTING IS PAID BY THE RESCUE)

Yes

No

Are your current pets up to date on all vaccinations and heartworm prevention, including distemper, parvo, lepto, Bordetella and rabies vaccines?

Yes

No

Pet Care Commitment

What type of exercise do you plan to provide your new pet?

How do you plan to train your new pet?

What type of training techniques have you used in the past, ( i.e. e-collar, etc.)

References

Please provide two references (other than family members): Include name, relationship and phone

Reference 1

Reference 2

Signature

By signing below, I affirm that the information provided is true and accurate to the best of my

knowledge. I understand that submitting this application does not guarantee adoption. Paws and

Purpose Rescue reserves the right to reject any application for any reason.

Signature

Signature field is empty.

Date

Month

Day

Year