SURRENDER OF DOG APPLICATION & AGREEMENT

The primary mission of Bichon Rescue of Orange County (BROC) is to help Bichons and other small breeds that can no longer be cared for by their owners. Although we concentrate our efforts on those in shelters or who have been abandoned or rejected, we realize that there are families who may no longer be able to care for them. We review and evaluate each surrender based on the information provided.

Please read the information on our Re-Homing Process page before completing this form. We will contact you to arrange a time to evaluate your dog and will advise you of the surrender donation following evaluation.

Thank you,

BROC Leadership Team

Have you read the animal surrender/rehoming information page on our website? *

Yes

No, not yet

Your Contact Information

First Name: *

Last Name: *

Driver's License Number: *

Your age: *

Street Address: *

City: *

State: *

Zip: *

Email Address: *

Home Phone: *

Cell Phone: *

Preferred Contact Method: *

Home Phone

Cell Phone

Email

Text Message

Occupation: *

Employer: *

Where did you hear about us? *

Reason for Surrender

Please explain the reason you wish to re-home the dog(s):

IMPORTANT: If you wish to re-home more than one dog, please complete a separate form for each dog.

*

Information About the Dog You Wish to Surrender

Dog's Name: *

Breed: *

Type *

Purebred

Mix

Not Sure

Age: (date of birth if known)

Sex: *

Male

Female

Spayed / Neutered *

Yes

No

Color and Markings: *

Weight: *

Under 10 pounds

11-15 pounds

16-20 pounds

20+ pounds

Height at the Shoulders *

Under 10 inches

Over 10 inches

Microchip Number *

Other Registration Number *

Where did you get the dog? *

How long have you had the dog? *

This Dog's Daily Routine

How many times a day do you feed your dog and what is his/her serving size? *

What brand and type of food does your dog eat? (Example: Blue Buffalo, Stella and Chewy, kibble, raw, etc) *

Is this dog housebroken? *

Yes

No

If not housebroken, please explain: *

Does this dog go for walks? *

Yes

No

If this dog does not go for walks, please explain: *

Does this dog like to ride in the car? *

Yes

No

If this dog does not like to ride in the car, please explain: *

Write a few adjectives that best describe your dog... *

Tell us how this dog gets along with others: *

Is this dog good with children? *

Yes

No

Is this dog good with other dogs? *

Yes

No

Is this dog good with cats? *

Yes

No

Is this dog comfortable around strangers? *

Yes

No

Has this dog ever bitten anyone? *

Yes

No

Is this dog destructive? *

Yes

No

Does this dog demonstrate any anxiety when left alone? *

Yes

No

Please explain any negative behaviors you have observed or have referred to in the questions above: *

Health Information For This Dog

Describe this dog's overall health, including how often he/she sees the vet and for what purpose? *

Veterinarian's First Name *

Veterinarian's Last Name *

Approx. Date of Last Vet Visit * +

Street Address *

City *

State *

Zip Code *

Vet's Phone Number *

Date of Last Rabies Immunization +

Date of Last Heartworm Test +

Date of Last DHLPP Vacinations +

Please provide a copy of your dog's vaccination record.

Additional Information

Please provide any other comments you would like us to consider about this dog: *

TRANSFER OF OWNERSHIP AND SURRENDER

By submitting this form, I acknowledge that I am the owner of the dog and I am fully authorized to enter into this Agreement. I proclaim that the information provided on this form is accurate. I understand that Bichon Rescue of Orange County will evaluate my dog before accepting him/her for surrender and rehoming. Once my dog has been accepted, I will hereby permanently and irrevocably transfer ownership of the dog to Bichon Rescue of Orange County. By executing this Agreement, I am irreversibly relinquishing to Bichon Rescue of Orange County all rights, title, and ownership that I had or may have had with respect to the dog.

By signing and submitting this form, I agree to the terms of the SURRENDER AGREEMENT.

Date: *

Adult's Signature Here: *

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