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:

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.

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.

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

Temperament & Training

Where does your dog stay during the day:

Has your dog ever snarled or snapped:

Additional Comments:

Vaccinations

Reason for Surrender:

Reason for Surrender*

Other Explained, Reason for Surrender:

Upload Photo's

Are you human?

Email

This field is for validation purposes and should be left unchanged.