Electronically is faster, and will guarantee faster processing of your application.
Please reply to all questions. If a question does Not apply to you then please put N/A in that space.
SHRR requires that the following conditions are met prior to excepting a dog into our Organization.
1. Current on vaccinations
2. Spayed or Neutered
3. Have a heartworm check
If these conditions are not met, the owner must make a $150 donation to SHRR
Personal Information
Name: *
Address: *
City: * State: * Zip:
E-Mail Address: *
Phone: *
Information on the Dog
Please tell us why you want to Surrender this dog. Please be specific.
Name of the dog:
Sex of the dog:
Date of Birth if known:
Age of the dog:
if Age is unknown, approximate:
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? an Outside Dog? Both?
Other Comments:
Medical History
If you are the present owner of this dog, please provide information about the dog's veterinarian:
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: Positive Negative (highlight/bold one)
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.
Other Comments:
Behavior
Is the dog housebroken? Yes No Not Sure
This dog needs to be confined to:
a) His/Her crate
b) a certain area of the house
c) a dog run/pen outside
d) leashed outside more than 4 hrs a day
e) Never confined. has 24 hr run of the house
Explain:
Will the dog allow you to examine it's body without much trouble?
How does the dog behave around adults? (select one)
a) Friendly
b) Shy
c) Nervous
d) Agressive
e) Other
Does the dog have any "gender specific" issues?
a) Difficulty with Men
b) Difficulty with Women
Other (specify):
Is the dog good around children?
How often has the dogs been exposed to childen?
Of what ages?
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? (select one)
a) Friendly
b) Shy
c) Nervous
d) Aggressive
e) Has to be Muzzled
f) Other
Please explain & be specific.
*Is the dog good and well socialized around:
a) Other Male Dogs: Yes No Not Sure
b) Other Female Dogs: Yes No Not Sure
c) Small Dogs: Yes No Not Sure
d)Cats: Yes No Not Sure
e) Other Small Animals: Yes No Not Sure
f) Livestock (Cows, Horses, Pigs, Chickens, Ducks) Yes No Not Sure
If you checked "No" in any of the 6 boxes 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 Comments:
Training
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?
Where?
Who taught the class?
Please explain.
Has the dog been Guard or Protection Trained? Yes No
Other Comments:
Are you able to foster this dog until a foster/adoptive home can be found? Yes No
How did you hear about Superior's Haven Rottweiler Rescue?
Space for additional comments:
I certify that the information provided on this form is true & correct. I understand that a physical evaluation of the dog, and a temperment test will be performsed by an experienced rescue volunteer to ensure we feel the dog is adoptable before we accept this dog into SHRR'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 above listed criteria must be met before SHRR will consider taking my Rottweiler as a owner surrender. I understand that if I am not able to meet these prerequisites, my circumstances I have explained above will be taken into consideration by SHRR in determining the acceptance of my Rottweiler as an owner surrender.
Signature: *
