QUESTIONS FOR SOMEONE GIVING UP A DOG. 1General Info2Previous Owner3Commands / Health4Characteristics InstagramThis field is for validation purposes and should be left unchanged.Date MM slash DD slash YYYY Dog's NameAgePresent OwnerAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Home PhoneWork PhoneChildren Yes No How ManyChildren's AgesOther Animals Yes No How ManyTypes of Other AnimalsWhere did you get this OES?Name of breeder/pet storeAddress of breeder/pet storePhone of breeder/pet storeHow long have you owned the dogReason for giving upSex Male Female Spayed Yes No Altered Yes No Tail Yes No AKC Records Yes No Coat length (puppy cut, full length, shaved?)Last groomed? (date)Groomer's nameGroomer's addressGroomer's PhoneDoes dog need to be groomed now? Yes No Matted? Yes No Need Bath? Yes No How does dog react to being groomed?Food typeFeeding scheduleHousebroken? Yes No How long can dog be left?What signal does dog give?Is dog on lead or left alone for "potty"? If you are the dog's first owner, please go to the next page. If you are the dog's second owner, any information known about the previous owner would be appreciatedPrevious Owner's NamePrevious Owner's Address Street Address 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 Previous Owner's Email Previous Owner's PhoneChildren Yes No How ManyAgesOther Animals Yes No How ManyWhat TypeReason for Giving UpVeterinarianVeterinarian Address Street Address 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 Veterinarian Phone Commands Dog Responds ToSit Always Sometimes Never Down Always Sometimes Never Stay Always Sometimes Never Come Always Sometimes Never Heel Always Sometimes Never Other CommandsIs the dog leash trained Yes No Behavior on leash Good Fair Bad Is the yard fenced? Yes No Is dog allowed to run loose? Yes No On leash at all times? Yes No Can you take dog for a walk off leash? Yes No CommentsHealth HistoryDo you have all medical records with you? Yes No Veterinarian NameVeterinarian 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 PhoneRabies Yes No Rabies Tag #Rabies Date MM slash DD slash YYYY Distemper Yes No Distemper Date MM slash DD slash YYYY Hepatitis Yes No Hepatitis Date MM slash DD slash YYYY Parainfluenza Yes No Parainfluenza Date MM slash DD slash YYYY Parvovirus Yes No Parvovirus Date MM slash DD slash YYYY Leptospirosis Yes No Leptospirosis Date MM slash DD slash YYYY Bordatella Yes No Bordatella Date MM slash DD slash YYYY Corona Yes No Corona Date MM slash DD slash YYYY Fecal Yes No Fecal Date MM slash DD slash YYYY Heartworm Date Tested MM slash DD slash YYYY Heartworm - Date last given MM slash DD slash YYYY Heartworm Type UsedDog's WeightPlease describe general health Typical day for the dogDescribe the dog's day: what time he eats, walks, plays etcHow many hours (maximum) can the dog stay alone?Is dog confined or allowed run of the house when alone?Has dog been crate trained? Yes No When left alone inside, is dog Loose Confined to a room Crated In Basement TemperamentPlease check all that best describe the dog: Aggressive Confident Dominate Excitable Heard-headed Laid-back Nervous Responsive Sedate Shy Stubborn Submissive Timid Hyper Puppyish Cooperative Frantic Characteristics / Behavior The following is a list of dog behavior problems. Please select either (always – sometimes – never). If always or sometimes, please provide details (when, where, why, etc.).Barking Excessively Always Sometimes Never Barking - under what conditionsBegging Always Sometimes Never Begging - under what conditionsBiting Always Sometimes Never Biting - under what circumstancesGrowling Always Sometimes Never Growling - under what circumstancesShowing teeth Always Sometimes Never Showing teeth - whenCar behavior when riding?Car Chasing Always Sometimes Never Car Chasing, under what circumstancesCar Sickness Always Sometimes Never Car sickness, whenCat Chasing Always Sometimes Never Cat Chasing, circumstances?Chewing - destructive Always Sometimes Never Chewing - describeDigging Always Sometimes Never Digging - describeDog Fighting Always Sometimes Never Dog Fighting - describeExcessive wetting Always Sometimes Never Excessive wetting - describeFood Guarding Always Sometimes Never Food Guarding - describeGarbage Ransacking Always Sometimes Never Garbage ransacking - describeAny issues with Grooming? Always Sometimes Never Grooming issues - describeHerding? Always Sometimes Never Herding issues - describeHouse-training "mistakes" Always Sometimes Never House-training Issues - describeDoes dog show jealousy? Always Sometimes Never Jealousy Issues - describeCan dog be trusted with young children? Always Sometimes Never Infant/child Issues - describeIs dog protective? Always Sometimes Never Protective? Of whom? When?How does dog react with strangers, other dogs and animals?Jump fences? Always Sometimes Never Jump fences? When?Jump on furniture? Always Sometimes Never Jump on furniture? Where?Jump on people? Always Sometimes Never Jump on people? When?Leash rejection? Always Sometimes Never Leash rejection? Describe.Does dog pull on the leash? Always Sometimes Never Leash pulling? DescribeMounting? Always Sometimes Never Mounting? DescribeNipping or mouthing? Always Sometimes Never Nipping or mouthing? Describe. When?Fear of confinement? Always Sometimes Never Fear of confinement? Describe.Fear of noises? Always Sometimes Never Fear of noises? Describe.Fear of people? Always Sometimes Never Fear of people? Describe.Running away? Always Sometimes Never Running away? When?Stealing food? Always Sometimes Never Stealing food? When? From where?Separation anxiety? Always Sometimes Never Separation anxiety? DescribeOther behavioral characteristics How soon must the dog go to a new home?Would you be willing to keep the dog until it is placed? Yes No Before this dog can be placed in a new home, he must be groomed, updated on inoculations and have a current heartworm test. We also recommend that the dog be altered. If the owner is unable to do these things, we ask for a donation to help cover these expenses. We realize that every situation is different and our main concern is the welfare of the dog. Thank you for your cooperation. I, (owner of said dog), have read, understood, and answered all of the above questions completely and honestly, making no misrepresentations concerning the temperament, health or behavior of the above named dog.Date MM slash DD slash YYYY Please type in your name
