Surrender Form * Required fields Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail* Reason for surrendering your pugDog’s name* DOB or age* Sex* Male Female Spayed/neutered* Yes No Colour Where did you get this pug (if from a breeder, please provide the name of the breeder)* How long did you have this pug* Veterinarian’s name and phone number* Date of last vaccination* MM slash DD slash YYYY Is this pug microchipped* Yes No If yes, please indicate microchipping company & and microchip*Did this pug ever had his teeth cleaned, if yes when* Does this pug has any medical condition that you are aware of, if yes, please explain*Does this pug ever had a surgery other than spaying/neutering* Yes No If yes, please give details and date of the surgery*Is this pug taking any medications, if yes which one* Is this pug good with other dogs* Is this pug dominant, if yes, how does he react to other dogs* Is this pug good with cats* How much, how often and what brand of dog food have you been feeding this pug* Where does this pug sleep at night* How many hours is this pug used to be left alone* Is this pug housebroken* Does he/she tells you when he/she needs to go outside* How often is this pug used to go to the toilet* Is this pug good with children of all ages* Will this pug allow you to trim his nails* Will this pug allow you to clean his ears, wash his face* How often is this pug bathed* Will this pug let you take its toys, treats, or food away* Is he/she aggressively protective of these things* Has this pug shown any signs of aggression toward human or another dog in the last 12 months* Yes No If yes, please explain in details*Does this pug have any behavioural issues such as excessive barking, territorial marking in the house, or separation anxiety* Does this pug ride well in a vehicle* Is this pug crate trained* Is there anything that we should know that will help us in finding a forever home for your pug*What type of family do you feel would be a good fit for this pug* I hereby relinquish custody of the above pug and do turn ownership of said pug to UNDER MY WING – Pug Rescue. I understand and agree that UNDER MY WING – Pug Rescue will assume responsibility for placing this pug in foster care until a permanent placement is arranged. By signing this agreement, I relinquish all rights to this pug. I understand that I no longer own this pug, therefore any medical expenses that are incurred on or after the surrender date are the responsibility of UNDER MY WING – Pug Rescue. I authorize the veterinarian listed herein to release all medical records concerning this pug to UNDER MY WING – Pug Rescue. I understand that my name, address, and phone number will not be released by UNDER MY WING – Pug Rescue to anyone unless I specifically authorize it. Name* First Last Signature* Witness* First Last Witness's Signature* Date* MM slash DD slash YYYY