OWNER INFORMATION:

Name:
Address:
E-mail address: Home Phone: Work Phone:

DOG INFORMATION:

Dog's Name: Age:

Sex: Male Female

Spayed or Neutered? Yes No

Color: Black Red Blue Fawn Albino

Ears: Cropped Natural

Tail: Docked Natural

AKC/CKC number: Breeder Name:

How long have you owned this dog?

Please list the date these procedures were last performed.

Vaccinations: DHLP-P Rabies: Bordetella:

Heartworm: Test: Result: Positive Negative

Is this dog currently on Heartworm preventative? Yes No

When is the last time this dog received Heartworm preventative?

What kind of Heartworm preventative? (ie: Heartgard, ProHeart6, Revolution, Interceptor)

If your dog is not up to date on vaccinations, heartworm preventative, spayed or neutered or is heartworm positive, are you
willing to make a donation to cover the costs of these procedures or willing to have them done before surrendering your dog?

Yes No

I would be willing to cover part of the costs, up to $

Why are you surrendering your dog?

Has this dog ever bitten anyone? Yes No Attempted (snapped, growled, etc.)

If this dog has bitten anyone, please tell us what happened in as much detail as possible:

Please tell us a bit more about your dog:

Is this dog good with: (check all that apply)

Other dogs

Cats

Birds & other small animals

Children

Where does your dog live now?

Outside at all times

Inside at all times

Crated inside

Outdoor kennel

Please tell us anything you feel is important about your dog:

When do you need to surrender your dog?

Finally, I understand that I will be required to turn over any AKC/CKC registration paperwork,
all veterinary records and sign an owner surrender form giving all ownership rights to
Gulf Coast Doberman Rescue.

Furthermore, I understand that GCDR makes no guarantees as to placement of my Doberman.