The Big Mutt Network Owner Surrender Form

Dog's Name:

Primary Breed:

Secondary Breed (if a mix breed):

Color:

Sex:

Estimated age/birthdate (if known)

Is your Dog altered?

How much does your dog weigh?

Does your dog have any kind of health concerns?

Why are you surrendering your dog(s)?

Is your dog micro-chipped? If so please provide vendor (i.e. Home Again, AKC) and microchip
number

Last Vaccination Dates for Annual DA2PP, Rabies, Bordatella, Corona:

Veterinarian's Name and Phone Number*

Has your dog(s) ever bitten another animal or human?

If yes, please explain (did the bite break skin, was it reported, has it happened more than once)

Does the dog have any known negative behaviors? (Please be as honest as possible to help us place
the dog in the right home)

Where did you get the dog (rescue, shelter, breeder etc) and how long have you had them?

Does the dog get along with:

If your dog isn't friendly with other dogs, cats, animals or humans please explain.

Do any of the following apply?

What brand of food, how much and how often does the dog eat?

Please select compatibility qualities:

We encourage you to donate any supplies/food you may have for your dog! Please list what you
We encourage you to donate any supplies/food you may have for your dog! Please list what you will be sending along with him/her (bed, food, bowls, crate, toys). While we do not charge a fee to surrender your dog we do appreciate donations.

I certify that the information entered on this application is true. Enter your initials.