Dogs Name:
Age:
Sex: Male Female
Spayed or Neutered: Spayed Neutered Will be done prior to surrender No
Breed and color:

Date of last rabies vaccination?
Date of last Heartworm test?

How long has this dog lived with you?
Where did you acquire this dog?

Who lives with this dog?
Men Women
Seniors Children, Ages:
Cat(s) Dog(s)

How would you describe the dog's behavior around children?
Friendly Playful Shy
Afraid Tolerant Never been around children

How would you describe the dog's behavior around other animals?
Friendly Playful Shy
Afraid Tolerant Never been around other animals

How would you describe your household?
Quiet Noisy Active Average

Do you have a fenced in yard ? Yes No
If no, how do you confine this dog?

Is your dog crate trained? Yes No

Does the dog have any previous injuries or health problems?

Has your dog ever bitten anyone Yes No

Why are you giving up this dog? Please be specific and honest.

What type of home do you think would be best for this dog?

Has this dog been raised around any other animals Dogs Cats   Other
Are they spayed or neutered? --- Please choose one -- Yes No

Please provide your vets information:
Clinic Name:
Phone:

I am the owner/caretaker of the above/described animal and have the legal right to execute this document. This animal is sound, in good health and to my knowledge has not bitten anyone. I hereby surrender all my interest in the animal to PawSafe Animal Rescue and request that the animal be cared for as PawSafe deems advisable.

PawSafe reserves the right to accept the surrendered animal on a trial basis and may, without prior notice, refuse to accept the animal or return the animal for whatever reason PawSafe deems just. Further, upon inspection of said animal, PawSafe reserves the right to refuse acceptance of said animal for whatever reason PawSafe deems just. If the animal is determined to be un-adoptable by PawSafe for any reason prior to placement, I agree to retrieve this animal within two (2) days following notification by PawSafe.

Any donation given to PawSafe is a non-refundable contribution. I understand that veterinary services needed prior to adoption will be my financial responsibility as well as any medical conditions not disclosed above.

Donation: $75 per dog, required

I agree I disagree