Franklin County Dog Shelter
Owner Surrender Information Form
OWNER INFORMATION
Name: ________________________________________________ Dog’s Name: _______________________________________
Address: ________________________________________ City: ___________________ State: ________ Zip: _____________
Home Phone: (
) _________ - _______________
Cell Phone: (
) _________ - _________________
Dog Breed: _____________________________________
Color: _________________
Sex: _________ Age: ____________
Spay/Neutered?
Yes
No
Is your dog microchipped?
(
) Yes
(
) No (
) Not sure
HOUSEHOLD HISTORY
Why are you surrendering your dog?____________________________________________________________________________
How long have you had your dog? ___________________ How many other owners has your dog had? __________________
Where did you acquire your dog? (
) Franklin County Dog Shelter
(
) Other shelter/rescue _________________________
(
) Friend/Relative
(
) Newspaper
(
) Found as a Stray
(
) Pet Store
(
) Own litter
(
) Received as Gift
(
) Breeder
(
) Craigslist
(
) Other _____________________________
How many hours a day is your dog: Indoors: ___________________________
Outdoors: _____________________________
When alone, where is your dog kept: (
) Free run of house (
) Confined to a room (
) Crated (
) Other: _____________
How many hours a day is your dog left unsupervised: ___________ During that time, is your dog: (
) Indoors (
) Outdoors
What ages of people have lived with your dog? Men: ___________ Women: ____________ Children: ____________________
Please describe your dog’s behavior with each of the following:
Men: (
) Friendly
(
) Playful
Women: (
) Friendly
(
) Playful
Children: (
) Friendly
(
)
Playful
(
) Tolerant (
) Afraid
(
) Tolerant (
) Afraid
(
) Tolerant (
) Afraid
What other animals has your dog lived with? Dogs (# and sex): ________________
Cats (# and sex): ____________________
Please describe your dog’s relationship with each:
Dogs:
(
) Wags Tail
(
) Plays
(
) Avoids
Cats:
(
) Wags Tail
(
) Plays
(
) Avoids
(
) Does Nothing
(
) Barks
(
) Snaps
(
) Does Nothing
(
) Barks
(
) Chases
(
) Other: _____________________________
(
) Other: ______________________________
DOG’S HABITS AND BEHAVIORS
Please circle adjectives that best describe your dog:
Friendly
Unfriendly
Affectionate
Aloof
High Energy
Lazy
Dominate
Fearful
Rough
Gentle
Quiet
Loud
Not Bright
Smart
Stubborn
Eager to Please
Please check any protective or possessive behavior your dog may display when you touch his/her:
Rawhide:
(
) Barks
(
) Growls
(
) Shows teeth
Food:
(
) Barks
(
) Growls
(
) Shows teeth
(
) Snaps (
) Bites
(
) Snaps
(
) Bites
Please tell us about your dog’s “bad habits”:
(
) Jumps
(
) Digs
(
) Barks/howls
(
) Chases cats
(
) Fights with other dogs
(
) Barks (when left alone)
(
) Destroys household items
(
) Accidents in the house