Surrender application

Please complete the form below.  For any fields that you do not have an answer (ie you do not have a current veterinarian) please type N/A.  Please make sure every field that has a star is filled out, even if it's just with N/A, otherwise the form will not submit.

Today's Date	*
What is the necessary date of surrender that you need the dog out of your house?
First Name	*
Last Name	*
Email Address	*
Address	*
City	*
State / Province	*	- - Choose One - - - - US States - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY - - Canada Provinces - - AB BC MB NB NL NT NS NU ON PE QC SK YT
Zip / Postal	*
Phone Number	*
Dog's name	*
Dog's Age	*
Dog's Gender	*	Male Female
Dog's Breed	*	Pug Puggle (Beagle/Pug Mix) Chug (Chihuahua/Pug Mix) Other Pug Mix
Is this dog housetrained?	*	Yes No Partially housetrained
Is this dog good with children?	*	Yes No
Is this dog good with other dogs?	*	Yes No
Is this dog good with cats?	*	Yes No Not sure
Name of Veterinarian	*
Veterinarian's Phone Number	*
Veterinarian's Address	*
Does this dog require immediate medical attention? **Your answer does not affect Curlytail's decision to place this dog in foster care, but rather helps us choose the foster home best equipped to provide the necessary course of medical treatment.	*	Yes No
If you answered "yes" to the question above, please list and describe the condition requiring immediate medical attention.
Has this dog ever been diagnosed with a medical condition?	*	Yes No
If you answered "yes" to the question above, please list and describe the condition as well as the prescribed course of treatment, including all medications or surgeries required to treat this medical issue, as well as any limitations to diet or mobility.
Has this dog received the prescribed course of treatment described in your answer above?		Yes No
Are you able to provide a medical history for this dog?	*	Yes No
Is this dog spayed or neutered?	*	Yes No
Has this dog ever had surgery other than a spay or neuter?	*	Yes No
If this dog has had surgery other than a spay or neuter, please describe.
Is this dog current on vaccinations?	*	Yes No
Does this dog suffer from allergies?	*	Yes No
Does this dog require eye or ear medication on a regular basis?	*	Yes No
Is this dog taking any medication currently (including heartworm preventative)? If so, what kind, and for what reason. Please give as much detail as possible.	*
If this dog is on heartworm preventative, what day of the month do they receive it?
When was the last time you brought this dog to a veterinarian?	*
What was the reason you last brought this dog to a veterinarian?	*
Has this dog ever bitten anyone? If yes, please explain.	*
What type of food do you feed this dog?	*
What time(s) of day do you feed this dog?	*
Does this dog suffer from anxiety? **If left alone, will he/she bark, cry or whine?	*
Please explain any behavioral issues this dog has exhibited.	*
Is this dog crate trained?	*	Yes No
Where is the dog used to sleeping?	*
Please choose the items that you can provide/send along with the dog.		Crate Blanket Bed Toys Food Food Dish Water Dish Medications Grooming tools
Approximately how many hours per day (on average) is this dog being left alone?	*
Is this dog tattooed or micro-chipped? (If yes, please provide company information and registry number).	*
Why are you giving up this dog? **Please answer honestly and openly, as we need this information so we can place this dog in the perfect, loving, adoptive family.	*
Photo #1
Photo #2
Photo #3
* I agree and understand that I am relinquishing all rights of possession and ownership of the described dog. I agree and understand that this dog is now the sole property of Curly Tail Pug Rescue. I promise that the information I am giving is accurate and that Curly Tail Pug Rescue will not be held liable or chargeable for any false information or misrepresentations that I may have submitted on this form. I further agree and understand that Curly Tail Pug Rescue will do whatever is necessary for the safety and well being of this dog.
* If you agree with the above statement, that you understand you are relinquishing your rights, please re-enter your first and last name.	*
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Status