Animal Surrender Agreement

Green Mountain Pug Rescue understands how difficult it is to give up a family pet. The detailed information you provide here will help us to place your dog in the best home possible.

State: Zip:
Reason for surrendering the dog:
Please complete the following questions with as much detail as possible.  
Dog’s Name:  
Where did this dog come from?    
How long have you had this dog?    

Veterinarian’s Name, Address and Phone Number:

Date of last vaccinations:
DHLPP   Rabies     Bordatella

Date of last heartworm test:   Results of test:  

Is the dog taking heartworm preventative?

If yes, what kind and dates to be given:

Lyme disease tested?

If the Lyme Disease test was positive, what was the date and result? 

When was the last dental cleaning done?    Extractions?  

Does this dog have any medical condition that you are aware of?

Is the dog taking any medications?

If the dog does take medications, what kind and dosage:

Have you traveled with this dog recently?

Do you know if it has been exposed to any diseases, such as Parvo, in the last 90 days?

How much, how often and what brand of dog food have you been feeding this dog?

Where does this dog like to sleep at night?

Is the dog housebroken?

Does it use a doggie door or tell you when it needs to go outside?

How often is the dog used to going to the toilet?

Is this dog good with children of all ages?

Will the dog allow you to trim its nails?

Will the dog allow you to clean its ears?

Will the dog allow you to wash its face?

How often is the dog bathed?

Who bathed it, you or a groomer?

Will the dog let you take its toys, treats, or food away?

Is it aggressively protective of these things?

How does the dog behave around other animals, especially cats and dogs?

Has the dog shown any signs of aggression in the last 12 months?

Has it ever bitten anyone?

Does the dog have any behavioral issues such as excessive barking, territorial marking in the house, or separation anxiety?

Does the dog ride well in a vehicle?

Is the dog crate trained?

Is the dog being surrendered a pug mix

If so, what type of mix?

If you are surrendering a pug mix, our rescue needs a photo of your dog to be sent via email to Judy Douglas at GMPR Board if Directors needs to approve the pug mix into our rescue. We do take mixes, but the dog must look like a pug. We have a harder time placing pug mixes so we need to be sure they look like a pug to place them in a loving home.

Is there anything else that we should know that will help us in placing your dog?

What type of family do you feel would be a good fit for your dog?

Please read and sign the following Agreement:

I on this date, do hereby relinquish custody of the dog(s) known as and do turn over ownership of said dog(s) to who is representing Green Mountain Pug Rescue.

  • I understand and agree that Green Mountain Pug Rescue will assume responsibility for placing the dog in foster care until permanent placement is arranged.
  • By signing this agreement, I relinquish all rights to this dog.
  • I understand that I no longer own this dog, therefore any medical expenses that are incurred on or after the surrender date are the responsibility of Green Mountain Pug Rescue.
  • I authorize the veterinarian(s) listed herein to release all medical records concerning this dog to Green Mountain Pug Rescue.
  • I understand that my name, address, and phone number will not be released by Green Mountain Pug Rescue to anyone unless I specifically authorize it.
By clicking “Submit” you agree that the above is your electronic signature and that the contents of this form are truthful and accurate.

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