Owner Surrender Form

Call Name *

Description of Dog: *

Color and Distinguishing Markings *

Gender: *

Female

Male

Spayed

Neutered

Date of Sterilization:

Age: *

Date of Birth:

AKC Registration Number if Registered:

Breeder (if known):

Sire: (if known):

Dam (if known):

Temperament & Training:

Dates of Last Vaccinations:

West Nile:

Rabies:

Annual Shots:

Heartworm Test:

Which Heartworm Preventative does the dog take:

When is next dose of Heartworm Preventative Due:

Name of Veterinarian:

Address of Veterinarian:

Phone Number of Veterinarian:

Medical or Medication Needed:

This agreement is entered into on this date: *

Between: *

and Sierra Pacific Great Pyrenees Club, Inc. Rescue for the placement of the above-described dog The person(s) giving up this dog understands and agrees that the above evaluation is for information/filing purposes only and that this dog will be placed with no guarantee or promise. The person(s) who are turning in the dog to Sierra Pacific Great Pyrenees Club, Inc. Rescue do hereby transfer and relinquish from its control the dog described above. It is agreed that the dog will be acquired and eventually re-homed as a companion animal under the Sierra Pacific Great Pyrenees Club, Inc. Rescue Contract For Adoption. It is further agreed and understood that the person(s) who is turning in the dog release and hold harmless the Sierra Pacific Great Pyrenees Club, Inc., its officers, directors, and members from any and all liability in connection with this dog.

First Name *

Last Name *

Phone Number *

Email Address *

City *

State *

Zip: *

Today's Date: *

SPGPC Rescue Volunteer: Pamela E. Tobin

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Owner Surrender Form

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