Surrender Survey

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First Name

Last Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Phone

Email

What is the Name of the Dog you are Looking to Surrender?

What is the Dogs Breed?

What is the Dogs Age?

What is the Dogs Gender?

How Much does the Dog Weigh?

Why do you Want to Surrender this Dog?

Has this Dog Ever Bit a Person Before? *

Yes

No

Does this Dog Get Along with Other Animals?

Does not get along with other animals

Dogs

Cats

Other

Has this Dog Lived with Children? If so, What Ages?

Is this Dog HouseBroken/Potty Trained? *

Yes

No

Is this Dog Crate Trained? *

Yes

No

Does This Dog Currently Have a Fenced-in Yard? *

Yes

No

Which Category Best Describes the Home in which the Dog Lives?

How Has this Dog Been Trained?

Positive Based Methods

Discipline Based Methods

Pack Leader Methods

Other

Is there a Training Facility/Person you Currently use?

Do you Have Any Behavior Concerns About this Dog? (If yes, please explain)

Is this Dog Up-to-Date on their Rabies Vaccine? *

Yes

No

Please Provide your Current Vet's Name & Phone Number (if applicable):

How did you Hear About Bullied Breeds Rescue?

Are you Willing to Give a Surrender Donation if we are Able to Help with your Dog?

I Certify that All Information About the Dog Listed Above is Accurate, Honest, and Discloses Any/All Known Behavioral Concerns.

Thank you! We’ll be in touch.

Contact

PO Box 225

Nutting Lake, MA 01865

info@bulliedbreedsrescue.org

License to Operate a Rescue Organization #0074

Your Name

Your Email

Subject

Message

Thanks for contacting us! We will be in touch as soon as we can.

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