Owner Surrender Request Form

MM slash DD slash YYYY
Form Completed By

Owner's Personal Information

Owner/Shelter Name(Required)
Address(Required)

Dog's Information

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Max. file size: 128 MB.
    You may upload more than 1 picture. Please email any additional images you are unable to upload to intake@goldenretrievers.org
    Dog's Gender

    Medical Information

    Are vet records for dog available?
    If no, is owner willing to make a financial contribution to offset GRRNT's Costs?
    Is dog current on all shots and vaccinations?
    If no, is owner willing to make a financial contribution to offset GRRNT's costs?
    Is dog on heartworm preventative?
    If no, is owner willing to make a financial contribution to offset GRRNT's costs?

    Behavioral Information

    Describe any type of anxiety or fear: Separation from owner, thunderstorm, car, fireworks, loud noises, etc.
    What is the dog's reaction to being in a crate?
    How much exercise does the dog need?

    Other Information

    Is the dog microchipped?
    This field is for validation purposes and should be left unchanged.