Personal info:

Name:

Address:

City/State/Zip:

Email Address:

Phone:

Dog info:

Where is the dog located?

Shelter City/State:

If you have more than one dog to surrender, than fill out one application for each dog, making sure your name and email address are on each application. If we have any further questions, we will contact you by phone or by email.

Please tell us why you want to Surrender this dog. Please be specific.

Name of the dog:

Sex of the dog:

Age of the dog:

Date of Birth if known:

Age is unknown, but approximately:

Is the dog Spayed or Neutered?

Does the dog have a tail?

Other Comments:

Please provide the following information to the best of your ability:

Dog General History

Where did you originally get/purchase/find the dog? Please be specific.

If you purchased the dog from a breeder, did you sign a contract giving the breeder right-of-first refusal?

Breeder's name:

Breeder's Phone Number:

Have you contacted the breeder?

If no, why not? Please be specific.

Is this dog AKC registered?

Do you have the papers?

Do you have a pedigree on this dog?

Is the dog an Inside Dog/Outside Dog/Not Sure?

Other Comments:

If you are the present owner of this dog, please provide information about the dog's veterinarian:

Medical History

Veterinarian's name:

Veterinarian's Phone Number:

If the dog has Not been spayed or neutered are you willing pay to have it done?

Has the dog been tested for heartworm?

If Yes, test was:

If the dog has not been tested for heartworm are you willing to have this done?

If the dog is heartworm positive are willing to pay for the heartworm treatment?

Is the dog currently on heartworm preventative medication?

If not, when was the last date that heartworm preventative was given?

If yes, what brand of heartworm medication has the dog been on?

Is this dog current with it's vaccinations?

If not, are you willing to have the dog given all his vaccinations?

Please provide other details of known/suspected medical conditions of this dog.

Behavior

Is the dog housebroken?

This dog:

Explain above answer:

Will the dog allow you to examine it's body without much trouble?

How does the dog behave around adults?

Is the dog good around children?

Is that experience:

Has the dog ever bitten or snapped at anyone?

If Yes, please explain & Please be specific.

Has the dog ever shown any aggression towards anyone or another animal?

If Yes, please explain & Please be specific.

How does the dog behave at the vet?

Please explain & be specific.

Is the dog good and well socialized around other male dogs?

Is the dog good and well socialized around other female dogs?

Is the dog good and well socialized around other small dogs?

Is the dog good and well socialized around other cats?

Is the dog good and well socialized around other livestock (Cows, Horses, Pigs, Chickens, Ducks)?

If you checked No in any of the 6 items above to do with other animals, please explain & be specific:

Do you feel the dog is overly possessive about his food/treats/toys?

Please tell us about other behavior issues this dog may have.

Other Behavior Comments:

Please list any commands the dog has knowledge of.

When on a leash, do you walk the dog? or does the dog walk you?

Has the dog had formal obedience training? Please explain.

Has the dog been Guard or Protection Trained?

Other Training Comments:

Are you able to foster this dog until a foster/adoptive home can be found?

How did you hear about Southern States Rescued Rottweilers, Inc.?

We reserve the right to refuse acceptance of any Rottweiler. Acceptance is based on many criteria, one of which is space availability. If you are out of our area, we will pass on your surrender form to another rescue.

I understand that the information contained in this form might be passed on to another rescue.

Additional comments:

I certify that the information provided on this form is true & correct. I understand that an physical evaluation of the dog, and a temperament test will be performed by an experienced rescue volunteer to ensure we feel the dog is re-homeable before we accept this dog into SSRR's program. If during the evaluation process we find that information contained in this surrender form to be false, we retain the right to turn down acceptance of the dog you are surrendering.

I also understand that the following criteria must be met before SSRR will consider taking my Rottweiler as a owner surrender. I also understand that if I am not able to meet these prerequisites, my circumstances I have explained above will be taken into consideration by SSRR in determining the acceptance of my Rottweiler as an owner surrender.

1. Current on vaccines
2. Spayed or Neutered
3. Have a heartworm check OR
4. The owner must make a $150 donation to SSRR

Signature (re-type email address):