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 direct your application to correct Rescue Team, 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:

Where did you aquire your dog and when?

Example: Shelter, Friend, Stray, Breeder, etc.

Breeder:

Please Provide Breeder Name, if you know what Breeder the dog was acquired.

Microchip Number:

Daily Life

Dog lives with:

Adults

Teenagers

Young Children

Animals dog lives with:

Cats

Small dogs

Large dogs

Other (rabbits, chickens, horses)

How does your dog interact with your family (both human and animal)?

What is your dog's daily activity routine?

What is your dogs favorite game or activities?

Where does your dog stay during the day:

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

Yes

Does your dog have a crate he sleeps in?

Temperament & Training

Likes?

Swimming

Car Rides

Grooming

Cats

Other Dogs

Is your dog?:

Housebroken

Crate Trained

Obedience Trained

Leash Trained

Hunt Trained

Does your dog:

Bark

Separation Anxiety

Resourse Guard

Act Agressive

Bite

What is your dogs personality?

Example: Energetic, Shy, Playful, Affectionate, Intelligent, Goofball, Lazy, Fearful, Aggressive to Strangers

Has your dog ever demonstrated aggressive behavior or bit a human or animal, please describe:

What are the best things about your dog?

Health & Vaccinations

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

DA2PP

Rabies

Bordatella

Corona

UNKNOWN

Heartworm Positive:

Yes

Hasn't been tested

Does your pet receive annual exams from a veterinarian?

How does your dog behave at the vet or groomer?

Name of Veterinarian, phone number, and address:

Does your dog have any medical problems, past or present?

Example: Diabetes, Seizures, Thyroid, Allergies

Diet:

Brand of dog food feed and amounts, timing

Reason for Surrender:

Reason for Surrender*

Explain reason for Surrender:

If we could help you resolve the issues surrounding the surrender of your pet, would you be interested in keeping your dog?

Any Additional Comments you wish to add:

What would you describe as the "perfect" home for your dog?

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 show off your other children, but these photos will potentially be used on our website.)

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