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

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:*

Gender:*

Male
Female

Spayed / Neutered:*

Yes
No

Purebred CBR:*

Yes
No

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
No

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
No
Hasn't been tested

Reason for Surrender:

Reason for Surrender*

Other Explained, Reason for Surrender: