Mail-In Owner Surrender Intake Form

Please email the completed application to boxeranglesdirectors@yahoo.com or mail or Fax to:

BAR
PO Box 543
N.
Bellmore, NY 11710
Fax:  212-971-2592

Name:________________________________

Address:__________________________________________________      State ____________   Zip Code:  ________________

Phone Number:_________________________       Best time to call:___________________________

Email Address:__________________________

Dogs Name:____________________________        Age/DOB:__________    Color:_______________  Gender:______________           

 Ears: _____Cropped ______Natural                        Tail: ____Docked ______Natural              Approximate weight: ____________

Please answer the following:

1.           Owner Surrender Fee suggested $100.00 _____________________________________________

2.             Name, address and telephone number of the Pet Shop, breeder or person you got the dog from:

_______________________________________________________________________________

3.             How long have you owned this dog?

                _______________________________________________________________________________

4.             Why is the dog being given up?

                _______________________________________________________________________________

                _______________________________________________________________________________

                _______________________________________________________________________________

5.             What is the name and address of the veterinarian who last treated and vaccinated this dog?

                _________________________________________________________________________________________________ 

6.  Has this dog ever been aggressive or vicious with human beings?  ________ Yes   __________  No

If yes, please describe the circumstances:  _______________________________________________________________________

_________________________________________________________________________________________________________

7.  Has this dog ever bitten anyone?     ________ Yes   __________  No

If yes, please describe the circumstances:  _______________________________________________________________________

_________________________________________________________________________________________________________

8.  Please provide us with the name and phone number of 2 people who know this dog that we may contact as a reference. who are not related to you.

     Ref. #1 – Name: ________________________________________________  Phone # _______________________

     Ref. #2 – Name: ________________________________________________  Phone # _______________________

9.  Please provide us with the town name of your local Animal Control Officer and their phone number .  _________________________________________________________

The following questions will be of help to the person who will adopt your dog. If there is anything you would like to add that may make your pet's adjustment to a new home easier, please feel free to share that information. We want to make the adoption a success and will work hard to have happy owners with happy dogs.

10.             Circle the adjectives that best describe your dog: - friendly - protective - shy - noisy - quiet - active - playful - nervous - smart                             
                      - affectionate - aggressive - obedient - calm

.               Is the dog current on vaccinations? Please list dates of vaccinations.

Rabies:____________        DHLPP____________            Bordatella__________     Lyme’s_____________                Any others?__________

11.           Date of last heartworm test: _____________          Neg___          Pos___                            Is the dog on heartworm preventative?          Yes___          No___

Brand of heartworm medication dog is taking?_____________________      Date of last pill?_________________________

12.           Is the dog spayed or neutered?_________________________________

13.           Date of last fecal exam for parasites__________________                   Results_____________                  If positive, was the dog treated?______________________

14.           Medications the dog is taking?    _______________________________________________________________________________

15.           Is the dog housetrained?      Yes____      No____        Partly____                             

                If partly, please describe when accidents occur:

                _______________________________________________________________________________

16.           Are there any behavior problems, if so what are they?

                _______________________________________________________________________________

17.           Does the dog get along with other dogs?___________           Cats?__________        Other animals?_________________

18.           Does the dog like children?_____________________       Are there children in the home?_________     Children’s ages: ___________________    

19.           What BRAND of dog food is the dog fed?_________________________________

Canned___       Dry___           Semi-Moist___                 or a combination_________________________

How much is the dog fed?_____________              How often is the dog fed?__________

Are there any specific feeding instructions you wish to share with the new owner? _____________________________________________________________

20.           Where does the dog sleep?  _______________________________________________________________________________

21.           Is the dog allowed on the furniture?_________            Is the dog crate trained?_______________

22.           Where did you keep the dog during the day?  _____________________       At night?       ________________________

23.           How does the dog react to being left alone?

                _______________________________________________________________________________

24.           Is it afraid of anything in particular? (thunder, men, brooms, etc.)

                _______________________________________________________________________________

25.           Describe any training the dog has had, or tricks it has learned:

                _______________________________________________________________________________

26.           Does the dog have any health problems?          Yes ___             No ___

If yes, please describe: _______________________________________________________________________________

27.           Does the dog like riding in the car?______________________________

28.           What is the dogs favorite toys or play thing ?     ___________________________________________________________________________________

                Favorite pastime?      _______________________________________________________________________________

29.           What does the dog like?   ___________________________________________________________________________  

30.           What does the dog dislike?     __________________________________________________________________________

31.           Does the dog jump kiddie gates or fences? __________      If yes,  how high does the dog jump:_________________

32.           Is the dog a digger? Yes ____ No ____  

33.           Is there anything else you can share that is special, unusual, or endearing about your dog that would help the new owner?

                _______________________________________________________________________________       

                _______________________________________________________________________________       

34.           Are there things you think a new owner ought to be aware of?

                _________________________________________________________________________________

               ____________________________________________________________________________

When surrendering the dog please bring the following items if you have them:

                Toys, bowls, crate, blankets, beds, food and any other items you may have so it will make it easier

               for the dog to adjust to his/her new home.

Please send digital pictures of the dog you wish to surrender to boxerangelsdirectors@yahoo.com
or to our Intake Coordinator Kristi at
boxerangelkristine@yahoo.com
or you can mail printed pictures to Boxer Angels Rescue, PO Box 543, N. Bellmore, NY 11710

 

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