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Surrender Form Application
First Name
Surname
Email
Address
Mobile Phone
Breeder exemption number:
Divers Licence number and state of issue
Are you the legal owner?
YES
NO
When did you get the dog/cat?
How was the animal obtained?
How long have you had the dog/cat?
Reason for surrender?
How many homes has the animal had?
Name of Clinic
Address
Phone
Alternative vet
Phone
Type of Animal
Dog
Cat
Name of Pet
Is your animal microchipped?
Yes
No
Do you know the Microchip number
Age of pet
Date of birth if know
Primary Breed
Primary Colour
Sex of Pet
Male
Female
Is your animal desexed?
Yes
No
Size of Animal
Tiny
Small
Medium
Large
XLarge
Weight
Please upload a photo of your animal
Is your animal currently vaccinated?
Yes
No
Unknown
Vacinations
Describe your animals personality ( Likes / Dislikes)
When was your animal last wormed?
Has your animal shown any behavioural issues such as aggression towards other animals or people?
Is your animal good with
Other dogs
Other Cats
Children
Small animals
Live stock
Whats your animals energy levels like
Where does your dog sleep at night?
What does your dog use as a bed?
Is your dog allowed on the furniture?
Is your animal a one person animal?
Does your dog like
Men
Women
Children
Does your dog jump on people?
YES
NO
How is your animal with strangers?
Does your dog know basic commands?
Is your dog obedience trained?
YES
NO
UNKNOWN
Is your animal house trained
YES
NO
UNKNOWN
Is your dog lead trained?
Has your dog been crate trained?
Can your dog use a doggie door?
Does your dog regularly have accidents inside?
Has your dog been known to chew furniture?
Does your dog dig?
Does your dog jump fences?
Has your dog been an escape artist?
Does your dig know how to swim?
Does your dog travel well in cars?
Does your dog bark at noises?
Does your dog bark excessively?
Does your dog bark at someone at the front door?
Does your dog exhibit aggression?
Does your dog guard food?
Does your dog gaurd other resources (Toys, People Etc)
Is your dog shy?
Has your dog ever bitten anyone?
Is your dog fearful of noises/storms?
Has the dog attacked anyone?
Has the dog attacked another animal?
Is there anything else we need to know about your animal?
What do you beleive would be the perfect fit for the animal?
Sign this form by writting your full name in the box provided and the date of signature
By ticking the box below I am confirming that I am the legal registered owner of the animal and have authority under law to hand the animal over to the Homeless Animal Society and Boarding Kennel Inc for rehoming.
Send
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