Surrender Form BETA Form "*" indicates 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 Phone*Email* Name of Dog* Breed of Dog* DOB / Age of Dog* Sex of Dog* Male Female Approximate current weight* Is the dog spayed or neutered?* Yes No If your female is not spayed - do you remember when her last heat cycle was (can be approximate) Is the dog current on its vaccinations?* Yes No Is the dog microchipped?* Yes No Reason for surrendering this dog?How long have you have this dog?* Where did you get this dog?* The dog is Housebroken Paper trained Sometimes has accidents Not housebroken Is the dog crate trained?* Yes No How many times a day is the dog exercised? Where is the dog kept when no one is home?* Where does the dog sleep at night?* How many hours is the dog left alone during a work day?* How does the dog act when left alone?*Dog's favourite activities?*Training Obedience classes Home training Private professional training No formal training Commands known* Sit Down Stay Come Heel Wait Lay down Speak Shake Roll over Other This dog has lived in the same household with Other dogs Cats Birds Other animals Children (ages 0-5) Children (ages 6-12) Children (ages 13-18) How does the dog get along with other animals noted above?*Check as many of the following that describe the dog's behaviour and habits* Barks a lot Escapes yard Friendly to people Friendly to other dogs Separation anxiety Digs Chews Unruly Shy Likes water/swimming Likes riding in cars Submissive wetter Reserved Affectionate Calm Outgoing Growls Plays fetch Jumps on people Whines Fearful Playful Chases cats Hyperactive Likes treats Walks well on leash Does the dog like the company of small children?* Yes No Does the dog like the company of cats?* Yes No Does the dog like the company of other dogs?* Yes No Is the dog overly protective of its foot/toys/treats?* Yes No Is the dog overly protective of family?* Yes No Is the dog overly protective of its property?* Yes No How does the dog react to strangers?*Has this dog ever snapped at a human or other animal? If yes, please describe when and why.*Has this dog ever bitten a human or other animal? If yes, please describe when and why.*What is the dog fed, how often and how much?*Please list any medication currently taken or special needs the dog may have.*Is there anything else we should know about this dog?*How soon does the dog need to be placed?*Are you reaching out to other rescues?* Yes No If we are not able to help, do you give consent for us to share your surrender form and contact details with rescues who may be able to help?* Yes No 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*