First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Home Phone

Cell Phone*

Address*

Phone number*

Dog's name*

What is the breed of the dog you want to surrender? Is it a mix? *

Approximate age of dog or DOB*

Gender*

Is dog spayed or neutered?
Choose all that apply: Yes No Not Applicable

Are there other pets in the home? Please list type, dogs, cats ect, Sex of animals and if altered or intact. *

Has your dog ever shown any aggression to other animals? Explain*

Color of dog

If a Doberman, are the ears cropped?

Please list whether tail is docked or natural*

Please list reason for surrender, be specific*

Please state how you came to be in possession of the dog*

How long have you owned the dog?*

Does dog have any special needs or medication?
Choose all that apply: Yes No Not Applicable

If yes, please explain

Is dog up to date on vaccinations/veterinary care?*

Do you routinely use a monthly Heart Worm preventative for your current, or past pets?
Choose all that apply: Yes No Not Applicable

Please provide name, phone number and address of current veterinary clinic*

Has your dog ever bit a human?*

Has dog ever bitten or exhibited aggressive behavior toward people or other animals?
Choose all that apply: Yes No Not Applicable

Please provide any other details of your dog that would be helpful for us to know*

Can you help transport the dog to a United Doberman Rescue volunteer for intake*

Did you purchase or acquire dog from a breeder
Choose all that apply: Yes No Not Applicable

Some breeders require by contract that dogs be returned to them, should an owner no longer be able to keep him or her. By submitting this form and entering your name below, you acknowledge that (a) you did not acquire dog from a breeder, or if you did that (b) there is no contractual obligation that said dog be returned to breeder, or (c) that you have contacted breeder and have full authority to release dog to United Doberman Rescue. Your signature below releases United Doberman Rescue from all liability concerning any and all contractual obligations with breeder. *

I certify that the information submitted on his Surrender Application is true and correct, and verify by signing below that I am surrendering my pet to UDR. I have exhausted all options to keep my pet. I verify and agree that the dog I want to surrender is owned by me. I give UDR permission to call my Veterinarian or anyone else who has had contact or interacted with my dog named in the form, to get any and all information about dog, and further, all records on my dog may be released directly to a representative of United Doberman rescue upon request. I agree to let UDR adopt my dog to a home found to be the best fit for my pet. I further understand, when a UDR representative takes possession of my dog, I willingly relinquish any further rights and ownership of my dog and know UDR will find a suitable home for my pet. I agree to provide all vet records and any papers that will help my pet while in foster care. I agree to transfer any micro-chip information over to UDR once my pet has been surrendered. I agree will submit a photo of the dog I want to surrender ASAP to dobermanrescue@hotmail.com. We will get a hold of you within 48 hours of submission of all information. Know we do not take in aggressive dogs, or dog that have no human bite inhibition. Please email us first if you are unsure and would like to discuss what possible options you have with an aggressive dog at dobermanrescue@hotmail.com. *