Owner Surrenders and Intake

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Intake Form

Please fill out application as complete as possible. All incomplete Applications will not be evaluated.

* denotes a required field

First Name *

Last Name *

Email Address *

Phone Number *

Alternate Phone (Cell): *

Street Address *

City *

State

Major Cross Streets *

What is the Dog's Name? *

Please tell us the dog's date of birth, if unknown, please list approximate age: *

Please list the primary breed of the dog. *

If this dog is a mix, please list the secondary breed here.

What is the sex of the dog? *

Is this dog spayed or neutered? *

If not, please tell us why?

Is this dog current on all shots (Distemper/Parvo, Rabies & Bordatella)? *


If not, please tell us why?

Please tell us why you are turning this dog in (please be specific): *

Please tell us where this dog primarily is kept.








Is this dog housebroken? *

Can/does the dog jump or climb fences? *

Can this dog be trusted by itself inside for extended periods of time? *

Can this dog be trusted by itself within a fenced yard? *

Is this dog crate/kennel trained? *

What kind (brand) of dog food do you feed this dog? *

This dog is good with (please check all applicable): *








This dog is NOT good with (please check all applicable):







Please check all the words/phrases that best describe your dog: *















Has this dog ever bitten a person? *

If you answered yes, please describe the circumstances (be specific):

Was a police report made?

Has this dog ever attacked another animal? *

If you answered yes, please describe the circumstances:

Where did you get the dog from? *



Has the dog been obedience trained by a professional obedience trainer? *

If you answered yes to the above question, who was the tainer (please list name and city/state)?

Has the dog been treated for any major illnesses? *

If you answered yes, please describe each illness and he outcome (be specific):

Does the dog have a current Veterinary? *

Please give us the Veterinarian's name and address. *

Do you agree to provide us with all the information we need to place your dog? *


Do you agree to foster the dog until we can find it a new home? *


Do you agree to our intake policies and procedures? *


Do you agree that you have answered all the above questions truthfully and to the best of your knowledge?? *


Please give us any other information that may help in placement of this dog or post comments here:

Please submit a photo of the dog you are turning in. (Please upload jpegs only)



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