Owner Surrender – **************

Name *

Current address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you have a mailing address different than your street address? *

Yes
No

Mailing address (if different than Street address) *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Cell phone *

Home phone

Name of Dog *

Sex of Dog *

Male
Female

Age of Dog *

Dog's birthdate

When did you acquire this dog (month and year)? *

How did you acquire this dog? *

Can you provide a photo of the dog? *

Yes
No

Upload picture(s) here. You can upload multiple photos.

Click or drag files to this area to upload. You can upload up to 5 files.

Reason for surrendering dog to rescue? Please be specific. *

When will this dog need to come to rescue? *

Will you transport this dog to us? *

Yes
No
Maybe

Breed of Dog *

Doberman
Doberman Mix
Other (enter breed below)

Other Breed

Color *

Other color

Ears *

Cropped
Natural

Tail *

Docked
Natural

Does this dog live inside or outside? *

Inside
Outside
Both

Is dog house trained? *

Yes
No
Somewhat (explain details below}

Provide details about house training *

Does the dog know any commands? Please List *

What food has the dog been eating? *

How many times per day is the dog fed? Amount? *

Veterinarian's name and phone number *

Last Veterinarian visit

Is this dog spayed or neutered? *

Yes
No, but I can have them spayed/neutered
No, I cannot have them spayed/neutered

Is this dog up to date on vaccinations? *

Yes
No, but I can have them vaccinated
No, I cannot have them vaccinated

Is this dog currently taking monthly heart-worm prevention? *

Yes
No, but I can have them tested for heart-worm
No, I cannot have them tested for heart-worm

Last time Heart-worm prevention was taken? *

Is this dog being used for breeding? *

Yes
No, not currently but has in the past
No, never been used for breeding

Does this dog have any medical conditions? *

Yes
No

Please give detailed list of medical conditions *

Is the dog on any medications or supplements? *

Yes
No

Please provide detailed list of medications or supplements? *

Does the dog have any food, medicine, or environmental allergies? *

Yes
No

Please provide detailed list of any food, medicine, or environmental allergies? *

Has this dog had any surgeries other than spay/neuter? *

Yes
No

Please give a detailed list of any surgeries other than spay/neuter *

Is this dog good with *

Has this dog ever bitten a human? *

Yes
No

Provide details regarding the incident(s) *

Has this dog bitten another animal? *

Yes, an animal in our household
Yes, an animal outside of our household
No

Provide details regarding the incident(s) *

Does this dog *

Please list any other negative traits for this dog *

Please list any positive traits for this dog not previously covered *

Does this dog have any fears of *

Please list other fears not previously covered *

How did you find Doberman Underground? *

Signature *

I state that I am the owner, or custodian acting in good faith, I give the above-described animal irrevocably to Doberman Underground. My signature waives any and all further rights of ownership to this animal. I understand that Doberman Underground has NO further obligation to provide any information regarding this animal. To my knowledge, no one has been bitten or injured by this animal. To my knowledge, the above answers are true and correct. By signing this Agreement electronically I agree to the terms set forth and that my electronic signature is the legal equivalent of my manual signature on this Agreement

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