First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County*

Email*

Home Phone

Cell Phone*

Alt Email

Date*

Name of dog*

Sex*
Choose one: Male Female

Breed/Mix of dog?*

Age of Animal?

Is the animal up-to-date with vaccinations?*

Is the animal fixed?*

Reason for surrender*

To your knowledge has this animal bitten or showed potential to bite in the past*

If yes, please describe the incident*

Surrender Dog Profile

I originally acquired my dog from*

How long have you owned the dog*

I would describe my dog as*
Choose one: A family Dog For Adults Only A One Person Dog

Frequency of accidents indoors*
Choose one: Often Occasionally Never

How often does your pet go outside*

Is the dog crate trained*
Choose one: Yes No Other

If other explain

How many hours at a time is he/she left alone in a day*

My dog currently lives with

How does your dog behave towards these and other animals it interacts with*

Where do you keep your dog during the day*

When left alone my dog: (Check all that apply)

My dog is afraid of (Check all that apply)

My Dog knows the following basic Commands: (Check all that apply)

Are there any additional Commands

My dog has the following health concerns*

My dog is currently on the following medication

Other helpful information about my dog*

Please review and sign below acknowledging the following: 

The above information reflects the animal in which I am surrendering to Humble Hounds MN. 
I am the owner of this animal and have full right to surrender him/her. 
I understand that I cannot ask for this animal back after this form is submitted and
Humble Hounds MN has taken possession of this animal. After the previous have occurred
this animal is now under the complete ownership of Humble Hounds MN.  
My signature below reflects that I have read and understand the information provided above and I am hereby releasing all rights for this animal to Humble Hounds MN. 

Your printed name on this form is equivalent to your signature. Print name here*

Dated signed*