Name of Dog:            Date:

Owner Name:

E-mail Address:

Address:

Phone (Home)   (Cell)   (Work)

How did you hear about us?

Purebred?  Yes     No    Not Sure

Breed?   Doberman    Dachshund

AKC Papers?  Yes     No

Sex:   Male     Female

Age:

Spayed/Neutered?  Yes     No

Color?

Microchipped?  Yes     No

Housebroken?  Yes     No

Good with Children?

Good with Cats?

Good with Dogs?

Obedience Training?

Bad Habits?

Health Problems?

Where did the dog come from?

Reason for not keeping the dog?

Bitten anyone?

*Due to the expense of placing a pet (Veterinary bills, transportation, advertising, food, phone calls, supplies, etc.)   How much can you donate? 

*If your dog has not been altered, microchiped, vaccines due,etc.  Would you be willing to remedy these issues prior to surrendering?

*I surrender ownership and all claims to the above mentioned dog to Las Vegas Doberman and Dachshund Rescue Group.

Owner Signature: (type name to sign)      Date: