First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Cell Phone*

Text/Pager Email

HOW DID YOU OBTAIN YOUR  DOG:

DOGS NAME: BREED OF DOG: WEIGHT OF DOG: MALE OR FEMALE: AGE*

How old is your pet?*

What brand and variety of food is your dog currently eating?*

IS HE/SHE HOUSEBROKEN?*

Veterinarian's Name and Phone Number*

HAS THIS DOG EVER BEEN AROUND CATS? HOW DOES HE OR SHE REACT?*

HOW DID YOU OBTAIN YOUR DOG?*

HOW LONG HAVE YOU HAD YOUR DOG?*

HOW MANY HOMES HAS THIS DOG HAD?*

IS HE/SHE LEASH TRAINED?*

DOES HE/SHE HAVE ANY BAD HABITS? DON’T WORRY, WE UNDERSTAND NOT ALL DOGS ARE PERFECT. PLEASE BE HONEST.*

DOES HE/SHE LIKE DOGS OF ALL SIZES?*

HOW LONG CAN HE/SHE BE LEFT ALONE?*

HOW DOES HE/SHE DO ALONE? DOES HE/SHE REQUIRE CRATED?*

IS DOG SPAYED OR NEUTERED?*

HAS HE/SHE EVER BITTEN ANYONE? EXPLAIN*

IS THIS DOG GOOD WITH CHILDREN OF ALL AGES? EXPLAIN IF NEEDED:*

IS HE/SHE ON HEARTWORM PREVENTION? WHAT KIND?*

PLEASE PROVIDE ANY INFORMATION THAT WOULD BE HELPFUL TO NEW OWNER:*

WHY ARE YOU GIVING UP THIS DOG?*

WHAT KIND OF HOME WOULD YOU RECOMMEND OR THAT YOU FEEL SHOULD BE AVOIDED? NO CHILDREN, NEEDS OTHER DOG, ETC.*

Write any additional comments you might have.

I AM RELINQUISHING CUSTODY OF MY DOG TO TIRED DOG RESCUE, PLEASE INITIAL.*