Surrender Form

Click here to download a printable version of this form

Dog Name:    Date of Birth:

This dogs is a: Rottweiler    Rottweiler Cross

Sex: Male    Female

Where was the dog originally purchased from?
Registered Breeder   Backyard Breeder   Private Rehome   Pet Shop   Other
If "Other", please describe:   

Is your dog registered with your local council?: Yes    No
If yes - Name of Council:

Has your dog been declared a dangerous dog?: Yes    No

Is your dog speyed/neutered?: Yes    No

Is your dog microchipped?: Yes    No
If yes - Microchip Number:    Microchip registry:

Please list any physical problems or allergies that your dog has:

Is your dog up to date on vaccinations?: Yes    No

Is your dog on heartworm preventative?: Yes    No
If yes - Date last administered:

Please indicate any other medications that your dog is on:

Has your dog lived with children?: Yes    No
If yes - How old were the children:

Is your dog good with children?: Yes    No

Has your dog lived with other animals?: Yes    No
If yes - What kind:

Does your dog get along with (please tick as appropriate):
Other male dogs   Other female dogs   Cats    Children   Strangers

What does your dog:
Like Best?:     Dislike?:    Fear?:

How does your dog spend its day? Where does it sleep?

Has your dog ever bitten a person?: Yes    No
If yes - Please describe the incident:

Has your dog ever bitten another dog?: Yes    No
If yes - Please describe the incident:

What dog food brand do you feed your dog, and how much/how often is your dog fed?

Has your dog had any training?: Yes    No
If yes - What type?:

If your dog was obtained as a puppy, did it ever attend puppy preschool?: Yes    No
If yes - with which organisation?:

Please list the commands, tricks, skills that your dog knows and is familiar with (include house and crate training):

Please list your dogs bad habits:

Please detail why you are giving up your dog:

How old was your dog when it first came to you?:

Please describe the ideal home for your dog:

Please include any other comments about your dog, anything that may help us in finding the best home:

Surrender Agreement:

I, the undersigned, do hereby surrender to Rottweiler Rescue of WA Inc., this Rottweiler named:

I certify that I am the owner of this dog, free and clear of all other interests. I also certify that this dog is not possessed of any dangerous or vicious propensities. The information I have provided about the history of this dog is true and complete to the best of my knowledge. I authorise Rottweiler Rescue of WA Inc. to place this dog into a new home at their discretion and the best of their ability. I irrevocably relinquish unto Rottweiler Rescue of WA Inc. all rights, title and interest in and to the dog surrendered. I hereby forever release, discharge and agree to hold harmless and indemnify the Rottweiler Rescue of WA Inc. program, its board of directors, its officers, members and agents from all claims, demands, actions, causes of action and liability of any kind whatsoever arising as a result of or in connection with the surrender and subsequent adoption or other disposition of this surrendered dog. I have read the above, I understand and agree to it.

Signature:     Print Name(s):

Address:     City, Post Code:

Home phone:    Email:

Rottweiler Rescue of WA Inc. Rescue Agent:

Signature: ____________________________________________  Print Name: _______________________________________________

Address: _______________________________________________________________________________________________________

City, State, Postcode: _____________________________________________________________________________________________

Home phone: _________________________________________ Email: _____________________________________________________

Date: __________________________________________________________________________________________________________



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Rottweiler Rescue of WA Inc.
Rottweiler Rescue of WA Inc.