Dog's Full Name:	

Owners Full Name:	

We are dedicated to finding the best possible home for your dog. To do this effectively, we rely on you to provide us with as much information as possible about the pet. Please fill in this form completely and please print legibly.  The more complete and accurate your information, the faster we will be able to successfully place the pet in a new home. Please include copies of health and shot records.
	 
(circle)		Male	 	or 	Female 
		Neutered	or 	Spayed
Dog's Breed:	
Dog's Color:	
Dog's Weight:	
What is the age of this dog? 	
Give Birth date if known: 	

Your Address: 		
			
City: 	
State: 	
Zip: 	
Home Phone:	
Work Phone: 	
Email Address:	

Why are you surrendering this dog? Please explain fully (use extra sheet if necessary):	
	
	

Has this dog ever bitten a human or other animal? 	Yes		No
(If yes, please be specific and use extra sheet to describe the circumstances completely.  If the dog has bitten, this does not necessarily mean we will reject the dog. However, we must know the degree of the aggression and what caused it, so please be honest and detailed in your description. Failure to honestly disclose this dog's biting history may cause you to be legally liable for future damages caused by this animal to any individual.) 
	
How did you obtain this dog?
Pet Shop (name, city, state)	
	
Breeder (name, city, state, phone):	
	
Newspaper ad (city and state and any other details you have about seller or breeder):
	
Other (please be specific):	


I have AKC Papers for this dog: 		Yes 		No 
If yes, please include. (We do not pass papers to adoptive homes but we do keep track of the origins of dogs coming in to rescue.)
Please describe the schedule this dog is currently on, such as when it is accustomed to going outside, where & how long:	
	
	
When is it fed?: 		AM 	PM	Both
Brand Name of Food:	
Wet or Dry?	
Amount fed?	

Describe how the dog reacts to: (please be specific) 
Children: 	
Strangers: 	
Cats: 	
Other dogs: 	
Being alone in the house: 	
Being alone in a fenced yard: 	
Grooming: 	
Vet Visits 	
Walking on a lead: 	
What does this dog dislike: 	
Fear: 	
Like Best: 	
Where does this dog sleep: 	
Where does this dog spend the day: 	
Current medications? 	
Ever been to formal training? 	
If yes, give specifics and history: 	
Please list specific commands that your dog knows and responds to: 	
	
	

Favorite toys or plaything: (Please donate) 	
Bad or unusual habits: 	
Any abuse that you are aware of toward this animal at any time: 	

Please use the space below, and if necessary, the back of this form to describe what you would consider a suitable home for this dog. (Describe best scenario and give reasons.) 

	
	
	



Health Section: 
Is your pet up to date on all annual shots including rabies? YES   NO
(If yes, please include a copy of the vet records showing this.)
If no, will you bring the pet up-to-date?	
Is your pet on heartworm preventative? 	
What type?	

Please attach copies of current health records from your veterinarian. Include shot history, type of shot, date last given, Rabies date last given. Also include a 
copy of the Rabies Certification. 

Please check any health conditions that are applicable and explain circumstances or attach an extra sheet to give us a complete overview of the health issues the pet has. 
Ear infections 		
Eye problems 	
Hip dysplasia 	
Renal problems 	
Skin problems 	
Other (explain) 	
	
Name of current veterinarian (or last vet that examined the dog). Include city, state and telephone number please!!
		
		
			
I attest that I am the legal owner of this dog and I hereby surrender this dog to Homeward Bound Pet Rescue & Referral, Inc. for placement in an appropriate home, to be determined by our group. (The information you provide us with is critical to that process.) I do this freely and by my own choice. I further understand that I am relinquishing all rights of ownership to this dog once it is turned over to rescue.  All information I have included in this form is truthful and accurate.

(I understand that a foster spot is not always available and I may need to hold on to the dog until one is found. I further understand that I do not relinquish ownership rights until the dog is physically turned over to a rescue representative.)

I understand that Homeward Bound Pet Rescue & Referral, Inc. is a non-profit organization that depends on funding from those seeking to find responsible, loving homes for their pet, as well as from those adopting the dogs. I would like to show my thanks by making the following monetary contribution to the organization to help the valuable work that it does:
$_______________________	


Owner's Signature		

Date signed		

Date dog turned over to rescue:	
Homeward Bound Pet Rescue & Referral, Inc. SURRENDER FORM


Homeward Bound Pet Rescue & Referral, Inc. 	Website: http://www.hbprr.org            
1589 Placer Drive
Fairbanks, AK 99712	(907) 457-6783					 Page 1 of 3