TENDER LOVING CANINE RESCUE

Specializing in the American Eskimo

A 501(c)(3) Non-Profit Organization

41-2061553

 

Finding New Forever Homes for Rescued American Eskimo Dogs since 2002

P.O. Box 216

Grove City, OH  43123

614-519-5705

or 614-519-3377

Ohio Chapter

Heart Bandits American Eskimo Dog Rescue

as of 01/22/06

 

OWNER SURRENDER

 

Date:

 
Personal Information
Name :
Address :
City :
State :
Zip Code :
Home Phone Number :
Cell/Alternate Phone Number :
Email Address :
   
Information Pertaining to the Dog
Name of Surrendered Dog:
Breed:

Birth date (if known):

Age:

Name of Breeder (if purchased from a breeder):

If the dog is registered, please list their numbers here:                                          UKC:

                                                                                                                                    AKC:

                                                                                                                                  Other:

Sex:
Spayed or Neutered:
What size is the surrendered dog:
What is the weight of the surrendered dog:
   
Health Information:  Your Veterinarian will be contacted.  Please contact him/her and give permission to discuss your past pet history prior to our call.
Veterinarian:
Vet Clinic Name:
Address: 
City, State, Zip: 
Telephone Number: 
Veterinarian Hours:
   
Vaccination Dates:  
     Rabies:
     DHLPP:
     Bordetella:
When was the last time the surrendered dog was tested for Heartworm and what was the result of the test: 

Positive          Negative
Is the dog currently on Heartworm Preventative?  Is so, what brand:
 
The questions below are to help us place your dog.  Please be honest! 
How long have you had this dog?
Are you the dog's original owner?
Where did you get your dog?
If you received your dog from a rescue, please provide the name of the rescue

organization.  Please also include their address and phone number.
Can he/she be left alone inside (without incident)?
For how long?
Does he/she occasionally make "mistakes"?
Is the surrendered dog:  
     good with kids: Yes          No          Not sure  (If you are not sure, please explain why in the comment section towards the end of the application).
     good with cats Yes          No          Not sure (If you are noy sure, please explain why in the comment section towards the end of the application).
     good with dogs Yes          No          Not sure (If you are not sure, please explain why in the comment section towards the end of the application).
     dog aggressive Yes          No
     housebroken Yes          No
     barker Yes          No
     a chewer (furniture, shoes, etc) Yes          No
Does he/she dig holes? Yes          No
Does he/she enjoy car rides? Yes          No
Does he/she jump or climb fences? Yes          No
Does he/she get into the garbage? Yes          No
Where does he/she sleep?
What is he/she afraid of (i.e. thunder, loud noises, etc)?
Has he/she ever bitten anyone?  If so, please explain in detail the circumstances of the incident.
Does he/she bark when someone is at the door? Yes          No
Does he/she adapt well to new situations and people? Yes          No
Does he/she know any tricks? Yes          No
Has he/she had any obedience training? Yes          No
What type of food is your dog currently being fed:

Please explain in detail as to why you are surrendering the dog:

I declare that I am the owner of the dog described above and that I have the authority  to transfer the ownership of this dog to Tender Loving Canine (TLC) Rescue - Specializing in the American Eskimo. Further, I declare that all of the information stated on this form is correct and is complete to the best of my knowledge.  I understand that falsification or omission of the information regarding described dog may result in my being held liable for further actions of this dog, for future medical expenses for this dog or for the legal expenses involved in any dispute of your right to surrender this dog to Tender Loving Canine (TLC) Rescue - Specializing in the American Eskimo.  I also understand that once I have given up the American Eskimo dog in question, I am no way to have him/her back unless certain agreements have been made with the Director(s) of Tender Loving Canine (TLC) Rescue - Specializing in the American Eskimo.

We ask the owner to make a monetary donation to Tender Loving Canine (TLC) Rescue - Specializing in the American Eskimo upon surrendering your dog to help cover the expenses for any vet care that is needed.

You will be required to sign an owner surrender form that will transfer all legal rights of ownership to us.  All medical records, rabies tag and certificate, microchip information, any medications that the dog is currently taking (including heartworm and flea preventative, and any other items you wish to send with the surrendered dog.

 

Signature

 

 

Date

 

 

    

 

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