Surrender Application

Please add the required information in the form below and once required data is populated & approved the Gift Release will be presented for signature. Document may also be emailed for signature depending on the information provided.

Date*

Contact Information:

Name:*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Please Enter your Primary Phone Number Here. This could be Mobile, Home, or Business.

Mobile Phone

Please enter Mobile phone number. This number may be used to send a text confirmation of your submission, and a link to allow you to come back to form to continue later or edit.

Email:*

Enter Email Confirm Email

CBR Region*

To help us direct your application to correct Rescue resources. Please select CBR Region matching the State of your Application Address.

Dog Information

Dog's Name:*

Dog's Age:*

Dog's Weight (lbs):

Please enter a number from 10 to 200.

Please enter dog's weight in pounds, estimate if you do not know exact weight.

Gender:*

Male

Female

Spayed / Neutered:*

Yes

Purebred CBR:*

Yes

If mixed, what is the mix:

Breeder:

Please Provide Breeder Name, if you know what Breeder the dog was acquired. (provide City, State, website of Breeder if known)

Tag ID:

Is there a location tag on dog? If so, please provide ID of Tag and provider.

Family Makeup

Dog lives with:

Adults

Teenagers

Young Children

Animals dog lives with:

Cats

Small dogs

Large dogs

Other (rabbits, birds, horses)

Temperament & Training

Likes?

Swimming

Car Rides

Grooming

Cats

Other Dogs

Is your dog?:

Housebroken

Crate Trained

Obedience Trained

Leash Trained

Does your dog:

Chew or dig

Bark

Jump on people

Resource Guard food

Resource Guard toys

Where does your dog stay during the day:

Can you leave him unattended in the house for long periods of time?

Yes

Has your dog ever snarled or snapped:

Additional Comments:

Vaccinations

Is your Dog current on Vaccines (check if current):

DA2PP

Rabies

Bordatella

Corona

UNKNOWN

Heartworm Positive:

Yes

Hasn't been tested

Reason for Surrender:

Reason for Surrender*

Other Explained, Reason for Surrender:

Photos and Documents

Drop files here or

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB, Max. files: 5.

Please add Photos of Dog to be surrendered. Please try to take photos of dog without other dogs, children or people in photo. (We know you love to so off your other children, but these photos will potentially be used on our website.)

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