Papillon Pals Rescue, Inc. Please fill out this form as completely as possible; do not omit any information about your dog in order to get a home for
1. Permanent Surrender: You are permanently surrendering to us the following described dog (the "Dog"):
Name: Gender: Male Female
Date of Birth: Date of Purchase:
Color/Markings: Weight:
Has the dog been altered? : Yes No
Breed of Dog:
You agree that you, your spouse and/or co-owners, if any, are irrevocably transferring and surrendering to us legal
2. Pet Information: You are providing the following information about the Dog, which you promise is true, complete and correct to the best of your
(a) Medical History Please provide us with a copy of the following: Copy of veterinary records (required for documentation)
Current vaccinations (most recent shots given and date)
List any surgeries (other than spay/neuter):
Illnesses (past and present):
Any physical problems or allergies:
Veterinarian and phone #:
Heartworm test dates and results:
Heartworm preventative medication brand:
Date last used:
Flea/Tick Preventative brand:
Date last used:
Current food:
Is this a prescription diet? Yes No When fed? 1X/Day 2X/Day Free feed kibble
(b) General Information
Are you the first owner of this dog? Yes No
If no, explain:
Did you buy this dog from a breeder? Yes No
Do you have a contract to return the dog to the breeder? Yes No
If applicable Do you know name of breeder?
Do you have registration papers for this dog or any information from a breeder?
Reason for releasing this dog to rescue: Too many dogs to take care of Can't afford to care for dog
Other If other, explain reason
Is this dog a stray? Yes No If yes, where was it found?
When was it found?
What condition was it found in?
What efforts have been made to locate the owner?
(c) Behavior
Is this dog good with children? Yes No
If no, explain:
Is this dog good with other dogs? Yes No If yes: All dogs Male dogs Female dogs
Is this dog good with cats? Yes No
Please rate the dogs general temperment: Very Energetic Active Average
Easy Going Couch Potato
Is this a one person dog?
Does this dog bark excessively? Yes No
Is this dog destructive (chewing, digging, etc)? Yes No
Does this dog mark (with urine) in the house? Yes No
Has this dog ever bitten? Yes No
If yes, please explain:
(d) Training
Where does this dog live?
Is this dog housebroken? Yes No
What words do you use to ask the dog to eliminate?
Is this dog crate trained? Yes No
Does this dog walk readily/easily on a leash? Yes No
Does this dog ride well in a car? Yes No
Has this dog had any basic obedience training? Yes No
What words/commands does the dog know?
Has the dog had any special training (hunting, agility, etc)? Yes No
If yes, please list training:
(e) Other Information:
Does this dog have any special grooming requirements?
What does this dog like? (toys, games)
What does this dog dislike/fear?
Is there anything else that you would like someone adopting this dog to know about him or her?
Observations by a Papillon Pals Rescue representative (please add any addtional comments here):
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3. No Guaranties: We make no representations or guaranties about our arrangements for the Dog. 4. No Liability: We are not liable to you for any losses, injuries, damages, costs, expenses or liabilities whatsoever sustained or incurred by you in connection 5. Entire Agreement/Modifications/Binding Effect: This written Agreement contains the sole and entire agreements between Papillon Pals Rescue, Inc. and you, and supersedes any other
Date this form completed:
OWNER PAPILLON PALS RESCUE, INC. BY:
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(Print Name) (Print Name and Title)
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(Street Address) (Street Address)
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(City, State, Zip) (City, State, Zip)
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(Telephone) (Telephone)
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(Email) (Email)
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(Signature) (Signature)
