Surrender Form G.R.E.A.T. Rescue of NE Florida, Inc. Owner Surrender Agreement Surrender Application * Name of Applicant First Last * Name of Owner First Last * Owner’s Address Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State ZIP Code * Owner’s Home Phone Owner’s Work Phone Owner’s Mobile Phone * Owner’s E-Mail Address Email Confirm Email * Is there a co-owner? Yes No Co-Owner's Name First Last Co-Owner's Address Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State ZIP Code Co-Owner's Home Phone Co-Owner's Work Phone Co-Owner's Mobile Phone Co-Owner's Email Address, if applicable Email Confirm Email Golden's Information * Name of Golden * Age of Golden * Origin of Ownership * Length of Ownership * Purebred? Yes No Papers? Yes No What is the breed mix? * Sex of Golden Male Female Neutered? Yes No Spayed? Yes No * Weight * Color Medical Information * Name of Veterinary * Veterinary's Phone Number * Any Veterinary Specialist(s) seen? Yes No Veterinary Specialist Name First Last Veterinary Specialist Phone Number Purpose of Specialist? If more than one specialist seen, please give details below including specialist name, phone number and purpose. * Date of Last Rabies Vaccination * Date of Last DHPP Vaccination * Date of Last Bordetello Vaccination * Date of Last Heart Worm Check * Brand of Heart Worm Prevention Given * Date Last Heart Worm Preventative Given * Brand of Flea Prevention Given * Date Last Flea Prevention Given * Any medical problems such as allergies, frequent ear infections, dental, fur loss, skin infections, etc.? Yes No Don't know Please explain medical problems. * Is the dog on any medications, supplements, etc.? Yes No Don't know Please list medications, supplements, etc. * Brand of Dog Food * Amount of Dog Food Given and How Often Social/Behavioral * Has the dog bitten a person? Yes No Don't know Please describe circumstances of the biting incident. * Has the dog bitten an animal such as a cat or dog? Yes No Don't know Please describe circumstances of the biting incident. * Do you own other pets? Yes No Please describe animal(s), breeds and ages. * Does the dog get along with female dogs? Yes No Don't know * Does the dog get along with male dogs? Yes No Don't know * Does the dog get along with cats? Yes No Don't know * Is the dog people/toy possessive? Yes No Don't know Comments on people/toy possessiveness. * Is the dog food aggressive? Yes No Don't know Comments on food aggression. * Is the dog storm phobic? Yes No Don't know Comments on storm phobia. * Is the dog afraid of loud noises such as fireworks? Yes No Don't know Comments on loud noises. * Is the dog crate trained? Yes No Don't know Comments on crate trained. * Is the dog house broken? Yes No Don't know Comments on house broken. * Is the dog accustomed to being alone? Yes No Don't know For how long is the dog left alone? Comments on not accustomed to being alone. * Is your dog destructive when alone? Yes No Don't know Please describe circumstances. * Does the dog dig? Yes No Don't know Comments on digging. * Does the dog jump or climb fences? Yes No Don't know Comments on jumping/climbing fences. * Does the dog prefer men or women? Men Women No preference * Name special activities, foods, etc. this Golden enjoys. * What does this Golden dislike/fear? * Has this dog had obedience training? Yes No Don't know Where did the dog have obedience training? * Does your dog know basic commands? Yes No What commands are known? * Do you have children? Yes No What are the children's ages? Release Information * What is the reason for releasing this Golden? * Can the Golden remain in your home until a suitable foster home has been committed? Yes No Maybe How long can the Golden remain in your home? Comments on no or maybe staying in your home. * Are you working with any other source to place this Golden? Yes No What other sources? * Are there any known disputes regarding your current ownership of this Golden (i.e. Is there anyone else who might have claim to this dog)? Yes No Please explain dispute. * Any other comments? How did you hear about GREAT? Photograph of Golden Please forward a picture of the Golden Retriever to be surrendered to firstname.lastname@example.org. You will also need to provide the Veterinary Records if this dog is selected to come into GREAT Rescue. Terms of Surrender Thank you for the confidence you have placed in GREAT Rescue of NE Florida Inc, also known as GREAT and GREAT Rescue by allowing us to re-home your beloved Golden Retriever. We understand this is a difficult decision and we assure you that we will do our best to find a wonderful, loving and responsible home for him/her. Please understand that this surrender is irrevocable and once your Golden Retriever is surrendered, GREAT will hold the title to your Golden Retriever and GREAT will have the sole right and authority to make all decisions regarding your Golden Retriever. Once surrendered, your Golden Retriever will not be returned. * Name of Surrenderer First Last Name of Co-Surrenderer First Last * I/we acknowledge that I/we have read and answered the above questions to the best of my/our ability, confirm that this Golden Retriever is owned by me/us and will abide by the terms of this surrender. I/we understand this surrender is irrevocable and I hereby renounce any and all claims to the above described Golden Retriever. It is my understanding that G.R.E.A.T. Rescue of NE Florida, Inc. and those who volunteer on its behalf are in no way liable whatsoever in any regard now or hereafter concerning the surrender of this Golden Retriever. I/We Acknowledge and Agree. * Date and Time of Surrender Form Submission Date HH MM AM PM * Please enter the characters below so we know that a human and not a fur baby submitted this application.