Surrender Form

Personal Information

Name (required)

Your Email (required)

Address

City, State, Zip

Home Phone

Where is the dog located:
 In a Shelter At an Animal Control Facility.
 Rescued by ME personally and is staying with ME
 I own the dog and it is still with me at this time. Other: (specify)

How long has the dog been in your or the shelter/AC's custody?

If you own the dog, please tell us why you must surrender it. Please explain in detail.

IF you are representing a Shelter or Animal Control Organization please give the following:
Organization Name:

Phone if other than above:

Contact Person if other than yourself:

About the Dog

(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 you are from animal control or a shelter with several animals, just fill out the "Other Comments" for each section below to describe the dogs. If we have any futher questions, we will contact you by phone or by email)

Information about the Dog

Name of the Dog:

Sex of the dog:  Male Female

Age of the dog (Birth Date if known)

Age is unknown, but approximately

Type of the dog:  Purebred Rottweiler Mix
If the dog is a mix, name other breed(s) mixed with: (best guess is ok)

Does the dog have a tail?  Yes No

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?  Yes No

Have you contacted the breeder?  Yes No

Is this dog AKC registered  Yes No

Do you have the papers?  Yes No

Do you have a pedigree on this dog?  Yes No

Is the dog an: Inside Dog Outside Dog

Other comments

Medical History

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

Has this dog been neutered or spayed?  Yes No

Has the dog been tested for heartworm?  Yes No

If yes, test was:  positive negative

Is the dog currently on heartworm preventative medication?  Yes No

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

Is this dog current with its vaccinations?  Yes No

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

Other Comments

Behavior

Is the dog housebroken? Yes No

This dog:

 needs to be confined to his/her crate. Explain
 confined to certain area of the house. Explain
 has the run of the house.
Explain

Will the dog allow you to examine it's body without much trouble?  Yes No

How does the dog behave around adults?  Friendly Shy Nervous
 Difficulty with Men Difficulty with Women
 Other

Is the dog good around children?  Yes No
Is that experience:  Good Questionable

Is the dog good and well socialized around (check all that apply but do not check if unknown):
 Other Male Dogs Other Female Dogs
 Small Dogs Cats Other Small Animals

Do you feel the dog is overly possessive about his food/treats/toys?  Yes No

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

Other Comments

Obedience:

Does the dog have knowledge of basic commands? (check those that apply)
 Sit Stay Come Down

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

Has the dog had formal obedience training? Please explain.

Other Comments:

How did you hear about Recycled Rotts, 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.  Yes No

Space for additional comments:

I certify that the information provided on this form is true & correct. I understand that an physical evaluation of the dog by an experienced rescue volunteer will be required before we accept surrender. If upon inspection we find that information contained in this surrender form to be false, we retain the right to turn down acceptance of the surrender at anytime during the evaluation.

Signature

Date

Recycled Rotts Inc.
PO Box 1082, Oswego, IL 60543