P.O. Box 626

East Amherst, NY14051

DOG SURRENDER FORMDATE: ______

The information you provide on this form will help us match your dog with an appropriate new home. Please be honest in your answers. BDSC accepts dogs based on space available and temperament assessment. Available space may delay response to this application for 2 to 3 weeks. Surrender assessments are done by appointment. Although we can not guarantee BDSC will accept your dog, please come to a surrender appointment prepared to surrender your dog at that time. You must provide proof of vaccinations (Parvo/Distemper and Rabies) in the form of veterinary records for us to accept your dog.

Owner: ______

Mailing Address: ______

Street Address: ______

City: ______State: ______Zipcode: ______

Day ph: ______Eve: ______cell: ______

Email: ______

Dog’s name: ______Age/DOB: ______
Weight: ______Gender: M/F
Spayed/Neutered? NO/YES At what age? ______Where? ______
Breed(s): ______
Colors/markings: ______
  1. Current Veterinarian: ______

Phone: ______

  1. Date of last vaccinations: Rabies: ______

Parvo/Distemper: ______Bordatella: ______

  1. Does your dog have any old/new injuries or health issues? NO/YES

If yes, please explain: ______

______

______

  1. Is your dog taking medication or supplements? List: ______
  2. Are you this dog’s first owner? YES/NO Explain where and why you got this dog: ______

______

  1. Number of people in your household: ______Gender/Ages: ______
  1. Does your dog get along with (circle all that apply)

Children Under Male dogsFemale dogsCatsLivestockBirds small animals

  1. Does your dog chase: (circle all that apply)

Adults Children skateboards Bicycles cars livestock birds small animals

  1. Has your dog ever growled at you or anyone? NO/YES Please explain circumstance: ______

______

  1. Has your dog ever bitten? NO/YES Who was bitten?

YouA childAdult friendAdult stranger

Please explain circumstance: ______

______

______

  1. Is your dog possessive of food or toys? ______

How does s/he react? ______

Who provokes response? Another dogA child A strangerYou

  1. Has your dog ever been in a dog fight that caused injuries serious enough to send either dog to the vet? Explain: ______

______

  1. Where does your dog normally stay at night? (Be specific) ______

______

______

During the day? ______

How long is the dog alone during the day? ______

  1. Is your dog…. House trained? YES/NO Crate trained YES/NO

Leash Trained YES/NO

  1. What kind of food does s/he eat? ______

When? ______Amount? ______

  1. Has the dog had any obedience training? YES/NO

What commands does s/he know?

  1. Does your dog (circle for Yes)
  2. Jump/climb fences?
  3. Bark a lot?
  4. Dig for something to do?
  5. Chew on things?
  6. Describe your dog’s personality: ______

______

______

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Please explain in detail why you wish to surrender your pet to BDSC: ______

______

BDSC’s Surrender Donation request (not required):

$25.00 for spayed/neutered dog- ($50.00 for an INTACT dog).

You agree that you, your spouse, and/or any co-owner of the dog described on this form are irrevocably transferring and relinquishing to BDSC legal ownership of said dog on the date of surrender/acceptance. This gives BDSC complete authority to take whatever actions in our sole judgment are necessary and in the best interest of the dog.
Owner’s signature: ______
Date signed: ______
*This is an application ONLY and does not obligate surrender or guarantee acceptance. Please do NOT send surrender fee with this form.

BDSC BOARD MEMBER Use Only

Date of Surrender/Acceptance: ______

Location: ______

By: ______

Board Member comments: ______