*First Name:
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*Last Name:
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*Address:
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*City:
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*State or Province:
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*Zip:
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*Phone (1):
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Phone (2):
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*E-mail Address:
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How Did You Hear About Us?
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Dog's Name:
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Dog's Sex:
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Dog's Age:
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Does the dog have AKC papers?
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Yes No
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Is the dog spayed/neutered?
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Yes No
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Dog's color and markings:
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Where did you obtain the dog?
(List breeder/pet store, shelter, or prior owner, town)
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How much did the dog cost?
(If applicable)
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How long have you had the dog?
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Your reason(s) for surrendering the dog:
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We understand that no dog is perfect. Please answer the following questions as honestly and accurately as possible so that we may better help in placing the dog in the best possible environment. Incomplete forms will not be accepted.
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Is the dog a:
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House dog Outdoor dog
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Where does the dog spend the majority of its time?
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Where does the dog sleep?
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How is the dog contained?
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Fence Kennel Chain Invisible fence
Trolley Roams (not contained)
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Will the dog run if loose?
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Yes No
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Has the dog ever escaped or jumped a fence?
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Yes No
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Is the dog crate-trained?
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Yes No
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Is the dog house-trained?
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Yes No
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Will the dog walk on a leash quietly?
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Yes No
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Will the dog come when called?
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Yes No
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Does the dog get along safely with cats?
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Yes No Unsure
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Does the dog get along safely with other dogs?
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Yes No Unsure
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Does the dog get along safely with children?
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Yes No Unsure
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Does the dog get along safely with strangers?
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Yes No Unsure
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Is the dog bothered by the presence of others (animals or people) while eating?
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Yes No
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What is the dog fed? (Please indicate type of food and brand name, e.g., Purina ONE, Pedigree Large Breed, etc.)
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Would you describe the dog as:
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Sedentary Active
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Is the dog destructive in the home?
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Yes No
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If you answered "yes" to the above question, please explain:
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Does the dog become anxious when left alone?
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Yes No
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If you answered "yes" to the above question, please describe your dog's anxiety:
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Is there any history of aggressive behavior against people or animals?
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Yes No
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If you answered "yes" to the above question, please describe the aggressive behavior:
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Please tell us everything you can about the dog's history, personality, quirks, etc.:
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Does the dog have arthritis?
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Yes No
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Does the dog have diabetes?
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Yes No
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Does the dog have hip or leg problems?
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Yes No
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Does the dog have other health problems?
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Yes No
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If you answered "yes" to the above question, please explain:
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Please answer the questions below to the best of your ability. If you don't know the date of a vaccination or test, simply say "unsure" or "don't know".
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Date of last DHLP vaccination:
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Date of last rabies vaccination:
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Date of last bordatella vaccination:
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Date heartworm preventative was administered, or date of last heartworm test:
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Date of last fecal exam for worms:
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Veterinarian's name:
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Veterinarian's phone number:
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Your Household
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Number of people in household:
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Ages of children:
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Do you currently own other dogs?
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Yes No
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If you answered "yes" to the above question, please list age, sex and whether spayed/neutered:
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Do you currently own other pets?
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Yes No
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If you answered "yes" to the above question, please list type, sex and age:
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How long can you hold the dog you want to surrender?
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Will you help transport him or her?
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Yes No
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Please contact your vet and authorize him or her to release information to National Pyr Rescue.
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Please send a digital photo of the dog (by email) or a regular photo (by post)—see addresses below.
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Again, please note that this is not a Transfer of Ownership form. That form will be provided at the time of the dog's surrender. At that time, you will also need to supply vet records and AKC papers, if any.
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Use the "Send" button below to submit your completed form online.
To mail or fax a completed form, use the address information below.
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