Canine Surrender Request Form - Spca - Virginia (Page 2 of 2) in pdf

Canine Surrender Request

Dog is aggressive towards (circle all that apply): Men

Women

Children

Cats

Male Dogs

Female Dogs

Other _______________________________

Does the dog have any (circle all that apply): Food Aggression? Leash Aggression? Fear Aggression? Resource Guarding?

Does the dog have a bite history, either documented or undocumented?

Yes

Other bad/aggressive habits or concerns: _____________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________

Has the dog had any structured training? Yes

No If so, where and when? ____________________________________________________

What commands does the dog know? __________________________________________________________________________________________________

Any Health issues: __________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________

Other things we should know? ___________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________

By signing below, I attest that I am the legal owner of this canine. I understand and agree that submitting this form

does not obligate the Stafford SPCA to take ownership or responsibility for this canine.

If the Stafford SPCA is able to accept the surrender of this canine, I understand I will be relinquishing all rights of

ownership. I also understand that, upon relinquishment, I may place no demands upon either the adopter or the

Stafford SPCA to maintain contact with this canine, or request information about the new owner(s).

I understand that there will be a surrender and listing fee in order for the Stafford SPCA to take ownership of this

canine, charged to me, at the discretion of the Stafford SPCA. In addition to a surrender fee, there will also be a

continuing care fee charged to me, equal to three months of food, flea, tick, and heartworm preventatives, and

possibly an additional fee in order to bring the canine up to date on deficient veterinary care upon surrender. The

surrender and continuing care fees will be non-refundable.

I attest that all information included in this form is truthful, accurate, and complete.

SIGNATURE

____________________

DATE

Staff Member: ______________________________________________ Title: ____________________________________

Form received date:

**Submission of this form via email, fax or other means of transmission does not obligate The Stafford SPCA to take responsibility

for this pet.

STAFFORD SPCA CANINE SURRENDER REQUEST

Revised 04032016

Canine Surrender Request Form - Spca - Virginia Page 2