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SURRENDER REQUEST FORM

ESSCLI - RESCUE

 


Our rescue organization is made up entirely of volunteers, so your donation will be used to help pay expenses incurred while caring for dogs until we find homes for them. Those expenses include veterinary care, animal shelter bail out fees, collars, leashes, and dog food, to name a few.

If you cannot use your browser to send a form, click here to open a Word document that contains this form, and then complete the form by hand and mail it to the address shown.


 

Dog's Name:
Origin? Breeder/Pet Store/Other:
Name of owner or Shelter:
Street Address:
City/Town:     
State:      Zip Code:
Phone numbers:        E-mail address:
PHYSICAL PROFILE:

Age:

Sex:  Male  Female

Ever Bite:

Yes   No

Weight:

Spayed/Neutered: Yes   No

House Broken:

Yes   No

Color:

Crate Trained:  Yes   No

Separation Anxiety:

Yes   No
Appropriate for older/younger/no children:
Previously lived with or behavior around cats:
Previously lived with or behavior around dogs:
Over all temperament?
   

Has this dog been turned down by any other Rescue Group?       

Yes   No
 
VETERINARIAN:   Is your dog up to date on the following:

Rabies:

Yes   No Distemper: Yes   No Heartworm: Yes   No

Intestinal Worms:

Yes   No Bordatella: Yes   No Lyme: Yes   No

Special Needs or Concerns:

REASON FOR SURRENDER:

Additional information or comments: