Surrender Form

Fill out the form below to submit your request online, or click here to download a PDF copy of the form to mail to us.

Fields marked with an asterisk (*) are required. For any required field that is not applicable, please enter "N/A."

Owner's Information

* First Name:

* Last Name:

* Address:

* City:

* State:

* Zip:

* Phone Number:

Alt. Phone Number:

Best Time to Call:

* Email Address:

Alt. Email Address:

* How did you hear about us?

Dog's Information

* Date of Birth:

* Age (Years and Months):

* AKC Papers?

Yes No

* Sex:

Male Female

* Spayed/Neutered?

Yes No

If yes, when?

* Tattoo?

Yes No

If yes, what is the number?

* Microchipped?

Yes No

If yes, what is the service and ID number?

* Color and Markings:

Dog's Health Information

* Please list any health issues and/or concerns with your dog:

Specific issues:

Arthritis Diabetes Hip/Leg

* Please list vaccinations and their expiration dates:

* Date of last Heartworm Preventative:

* Date of last Fecal Test:

* Date of last Heartworm Test:

* Result of last Heartworm Test:

Positive Negative

* Date of last Lyme Test:

* Result of last Lyme Test:

Positive Negative

Dog's Breeder Information

Breeder Name/Location:

Rescue Organization/Location:

Pet Store/Location:

Other (Please Describe):

* If you purchased from a breeder, have you notified them of your intent to surrender?

Yes No

* Current Feeding Routine (Please specify brand, quantity, times per day, etc...):

* How long have you had the dog?

* What is your reason for surrender?

* Where does the dog spend the majority of its time?

* How is the dog contained?

Other Equipment

Dog's Training Information

* Has the dog ever escaped or jumped a fence?

Yes No

If yes, please explain:

* Does your dog run if loose?

Yes No

* Does your dog come when called?

Yes No

* Does your dog walk quietly on leash?

Yes No

* Does your dog dig?

Yes No

* Is your dog house-trained?

Yes No

* Is your dog crate-trained?

Yes No

* Has your dog received obedience training?

Yes No

If yes, please indicate the duration of the training:

Dog's Temperament Information

* Is your dog considered safe with children under 13?

Yes No

* Is your dog considered safe with teens?

Yes No

* Is your dog considered safe with strangers?

Yes No

* Is your dog considered safe with other dogs?

Yes No

* Is your dog considered safe with cats?

Yes No

* Please explain any history of biting or any other aggressive behavior towards humans or other animals:

* Does your dog show food protection behavior?

Yes No

If yes, please explain:

* Is your dog destructive in the home?

Yes No

If yes, please explain:

* Does your dog become anxious when left alone?

Yes No

If yes, please explain:

* Describe your dog's personality:

Sedentary Active

* Please explain your dog's history, personality, quirks, etc...:

* Please list the people in your household and their age:

* Do you own other dogs?

Yes No

If yes, please list ages, sex, and spay/neuter information:

* Do you own other pets?

Yes No

If yes, please list ages, sex for each pet:

* How long can you hold your dog:

* Will you help transport your dog?

Yes No

* Veterinarian's Name:

* Veterinarian's Phone:

Please contact your vet and authorize them to release information to Northeast Pyr Rescue.

The following items must accompany the dog when surrendered:

Veterinarian Records
AKC Papers (if available)
NEPR Surrender Form
Current Rabies Certificate (MANDATORY)
Current Photo of Dog
Dog's History/Personality Information (for listing on Petfinder and our website)

* Other comments:

Getting Involved

Surrender Form

Owner's Information

Dog's Information

Dog's Health Information

Dog's Breeder Information

Dog's Training Information

Dog's Temperament Information