Submission Listing: (must be in direct contact w/ owner or rescue agent)
First Name: Home Email:
Last Name; Home Phone
Home Address: City: State: Zip Code:
Work Name: Work Phone:
Work Email: Fax Phone #
Information
Requested: (please
complete as best as possible)
Dog's Name and/or ID: Sex:
male___ female___
Age: (in years) Breed
Color: (or best estimate)
Coat Type:
Other Markings:
If other, please describe now:
Current Health Status: (please give all pertinent details)
|
spayed/neutered |
yes___ |
no___ |
details |
|
recent vaccinations |
yes___ |
no___ |
details |
|
heartworm negative |
yes___ |
no___ |
details |
|
heartworm positive |
yes___ |
no___ |
details |
|
kennel cough |
yes___ |
no___ |
details |
|
ear infection |
yes___ |
no___ |
details |
|
eye infection |
yes___ |
no___ |
details |
|
entropion |
yes___ |
no___ |
details |
|
allergy symptoms |
yes___ |
no___ |
details |
|
bone damage |
yes___ |
no___ |
details |
|
flea / tick infestation |
yes___ |
no___ |
details |
Preferred monthly heartworm preventative / last date given:
Any other known medical treatments / surgeries still needed:
If known, vet's name, address, phone #, clinic name:
Basic Temperament Description: (please mark all that apply)
Is your dog best described as
Housing Preference: Sleeping
Habits:
Obedience Level: Favorite
Reward:
Personality preferences: (yes if they like, no if they dislike, sometimes if it varies)
|
OTHER DOGS |
yes___ |
no___ |
details |
|
CATS |
yes___ |
no___ |
details |
|
OTHER SMALL ANIMALS |
yes___ |
no___ |
details |
|
CHILDREN |
yes___ |
no___ |
details |
|
STRANGERS |
yes___ |
no___ |
details |
|
CRATETRAINED |
yes___ |
no___ |
details |
|
HOUSETRAINED |
yes___ |
no___ |
details |
|
LEASH WALKING |
yes___ |
no___ |
details |
|
CAR RIDES |
yes___ |
no___ |
details |
|
VET VISITS |
yes___ |
no___ |
details |
|
BOARDING |
yes___ |
no___ |
details |
|
BATHING |
yes___ |
no___ |
details |
|
NAIL CLIPPING |
yes___ |
no___ |
details |
|
EAR CLEANING |
yes___ |
no___ |
details |
|
LEFT ALONE |
yes___ |
no___ |
details |
|
IN CROWDS |
yes___ |
no___ |
details |
How long have you owned this pet? (please list length of time you've had or the date found if stray)
I have been the owner for / found dog on: years___ months___ not my dog___
Why are you giving this dog away? (please feel free to list more than one reason)
Can you foster this dog until a new home is found?
YES___ NO ___ LIMITED TIME
please list date you can keep the dog until:
Where did you get this dog in the first place?
breeder___ petstore___ friend___
If known, breeder's name, address, phone#, website:
|
BREED VERIFICATION: Pictures and independent evaluations are generally required to be accepted into any responsible breed rescue and/or promoted in our network PAL feature program. If you can provide pictures at this time, please send a seperate email to Tina Wissen today! BY CHECKING THE APPROPRIATE BOX BELOW, I ACKNOWLEDGE THAT ALL THE INFORMATION CONTAINED ON THIS FORM IS TRUE AND CORRECT, AND I UNDERSTAND THAT ANY FALSE ATTEMPTS WILL RESULT IN THE IMMEDIATE DELETION OF MY SUBMISSION. I AGREE ___ I DISAGREE___ |
Please sign if returning by mail:
_____________________________________________________DATE:___________________
Please contact us if you don't know how to cut & paste this form into an email.