Owner Surrender Form

Dog's Name*

Upload photo of the head only:

Max. file size: 512 MB.

Upload photo of whole dog

Max. file size: 512 MB.

We will need a photo of your dog for the web site, please keep the file size < 200KB

Gender*

Size*

Age*

Coat color*

Eye color*

About My Dog

Please write information about your dog you think is important.

Children*

How is your dog with children?

Other Dogs*

How is your dog with other dogs?

Cats*

How is your dog with cats?

Other animals*

How is your dog with small animals like rabbits, hamsters, fish, birds etc?

Housebroken*

Please select the option that best describes your dog's housebreaking training.

Breed*

What breed is your dog?

Dog Photo #2

Max. file size: 512 MB.

You can provide a second photo if you wish, please keep the file size < 200KB

Training completed

Please check all that apply to your dog's training.

Behavior Problems

Please check off all the areas where your dog needs training or has caused troubles

Your Name*

First Last

Address*

If you live outside of PA, NJ, DE, or MD, you will have to contact us to discuss your situation

Street Address Address Line 2 City State ZIP Code

What County do you live in?*

Email*

Home Phone*

Alternate Phone

Reason For Placement*

Please explain why you must find a new home for your dog.

About my dog

Tell us more about your dog.

Bite disclosure*

Has your dog ever bitten? If not, please indicate here. If yes, please explain the circumstances.

Timing*

Please select, keep in mind the longer you can hold, the more likely we can help.

Owner Entry Validation*

You must validate the information presented here.

Placement fee*

Please select the terms that apply to your situation.

Veterinarian Info*

Please provide your current vet name, address, and phone number.

Neuter Status*

Rabies Vaccine*

When was your dogs last rabies vaccine (month/year)?

Combo Vaccine*

When was your dogs last distemper combo vaccine (DHLP, DP, Etc)?

Heartworm test*

When was your dog last tested for heartworm and what was the result?

Medical notes

List any known medical problems with your dog.

Dog's Birthdate

Microchip ID

If microchipped, enter number here.

After clicking on Submit, DO NOT REFRESH or RESUBMIT. You will receive a confirmation message (and email) if you successfully submitted this surrender form. If the form still appears, review for missing Required fields and enter the requested information.

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