Lhasa rescue network surrender form

(circle) Male or Female

Neutered or Spayed

Dogs Color:

Dogs Weight:

What is the age of this dog?

Give Birth date if known:
Your Address:

City:

Zip:

Work Phone:

Email Address:
Why are you surrendering this Lhasa Apso? Please explain fully (use extra sheet if necessary):
Has this Lhasa ever bitten a human or other animal? Yes No

(If yes, please be specific and use extra sheet to describe the circumstances completely. If the dog has bitten, this does not necessarily mean we will reject the dog. However, we must know the degree of the aggression and what caused it, so please be honest and detailed in your description. Failure to honestly disclose this dog’s biting history may cause you to be legally liable for future damages caused by this animal to any individual.)

Petshop (name, city, state)-

Breeder (name, city, state, phone):

Newspaper ad (city and state and any other details you have about seller or breeder):

Other (be specific please):

I have AKC Papers for this Lhasa: Yes No

If yes, please include. (We do not pass papers to adoptive homes but we do keep track of the origins of dogs coming in to rescue.)

Please describe the schedule this dog is currently on, such as when it is accustomed to going outside, where & how long:

When is it fed?: AM PM Both

Brand Name of Food:

Wet or Dry?

Amount fed?

Children:

Strangers:

Cats:

Being alone in the house:

Being alone in a fenced yard:

Grooming:

Vet Visits

Walking on a lead:

What does this Lhasa Dislike:

Fear:

Where does this Lhasa sleep:

Where does this Lhasa spend the day:

Current Medications?

Ever been to formal training?

If yes, give specifics and history:

Please list specific commands that your Lhasa knows and responds to:
Favorite toys or plaything: (Please donate)

Bad or unusual habits:

Any abuse that you are aware of toward this animal at any time:

Please use the space below, & if necessary, the back of this form to describe what you would consider a suitable home for this Lhasa Apso. (describe best scenario and give reasoning please.)

Is your pet up to date on all annual shots including rabies? YES NO

(if yes, please include a copy of the vet records showing this.)

If no, will you bring the pet up-to-date?

Is your pet on heartworm preventative?

What type?

Ear infections

Eye problems

Hip dysplasia

Renal problems

Skin problems

Other (explain)

Name of current veterinarian (or last vet that saw dog). Include city, state and telephone number please!!

I attest that I am the legal owner of this Lhasa Apso and I hereby surrender this Lhasa Apso to the Lhasa Apso Rescue Network for placement in an appropriate home, to be determined by our group. (The information you provide us with is critical to that process.) I do this freely and by my own choice. I further understand that I am relinquishing all rights of ownership to this Lhasa Apso once it is turned over to rescue. All information I have included in this form is truthful and accurate.
(I understand that a foster spot is not always available and I may need to hold on to the dog until one is found. I further understand that I do not relinquish ownership rights until the dog is physically turned over to a rescue representative.)
I understand that the Lhasa Rescue Network is a not-for-profit organization that depends on funding from those seeking to find responsible, loving homes for their pet, as well as from those adopting the dogs. I would like to show my thanks by making the following monetary contribution to the organization to help the valuable work that it does:

$

Your check will only be deposited when the dog is placed in a new home.

Owners Signature
Date signed
Date Lhasa turned over to rescue: