First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Cell Phone*

What is the name of your dog ?*

What is the age of your dog ?*

How long have you owned your dog ?*

What is the breed (kind) of your dog and is it a mix or purebred?*

Describe the coloring of your dogs fur*

How much does your dog weigh?*
Choose one: Less than 5 lbs 5 lbs - 8 lbs 9 lbs - 15 lbs 16 lbs - 20 lbs 20 lbs - 30 lbs 30 lbs - 40 lbs greater than 40 lbs

Is your dog microchipped ?*
Choose one: Yes No

Please tell us why you need to surrender your dog.*

Where did you get this dog from originally ? If from a pound, shelter or rescue, what is the name of where the dog is from*

Is your dog current on these vaccinations? Check all that apply

Check box that applies

Has your dog ever bitten anyone where there was an injury?*
Choose one: Yes No

If a bite occurred, explain the circumstances of the bite*

Choose all that apply about your dog

Does your dog react poorly, fearful, anxious or aggressive in these situations ? Check all that apply
Choose all that apply: Strangers at door Men Women or Children Loud Noises like firework Kids playing near them Around food When on leash near other dogs People petting him or her Barks when left alone Unsettled when left alone Digs in the yard

Where does your dog sleep at night ? *

Describe any health or behavioral problems your dog has*

How long are you willing to foster your dog while we find a new home?*
Choose one: 1-2 weeks 3-4 weeks 2-4 months Until a home is found Cannot foster at all Will pay you for boarding my dog

Can you contribute to NWTLB towards the care of your dog?*
Choose one: Whatever is required $200 or more $150 $100 $50 Cannot contribute

I understand that NWTLB is a Non-Profit 501(c)3 organization that relies on donations in order to care for dogs like mine*
Choose one: Yes No

I understand that my dog will need to be current on vaccinations and altered or NWTLB may require an additional donation to cover this expense. I will provide a copy of all medical records to NWTLB prior to surrender I will provide any of my dogs favorite toys, dishes, beds or other items that will help my dog adjust to being given away.

I understand and acknowledge by submission of this form, I am requesting NWTLB accept ownership of my Dog and that NWTLB has not Agreed to take my Dog until such time that a formal transfer of ownership is finalized. I understand this submission is a request to NWTLB and does not imply NWTLB will take my Dog. *
Choose one: I Agree I Do Not Agree