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Owner Surrender

Anderson Humane Society

Pet Surrender Form

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In order to better care for and find a home for your pet, we ask that you please be honest with us on this form.

Your Information

Your Name *

Phone *

Work Phone (optional)

Address

Email *

Are you the owner of this pet? *

Yes No

If not the owner, please explain

About Your Pet

Pet Type *

Dog Cat

Pet's Name *

Breed / Description

Sex

Male Female

Spayed / Neutered?

Yes No

Pet's Age

Micro-chipped?

Yes No

Chip #

Which Company?

Was this pet adopted from a Rescue or Animal Shelter?

Yes No

If yes, when & where you adopted it from

If no, how / where you got it

How long have you had this pet?

Reason you need to surrender this pet? *

Health & Care

Who is your veterinarian?

Vet Phone

Is this pet current on vaccinations?

Yes No

Please list any medical conditions you know of

Does this pet require a special diet?

Yes No

If yes, which type?

Where does this pet spend most of its time?

Inside Outside Both

Fenced Yard?

Yes No

Crate Trained?

Yes No

Outside Kennel?

Yes No

Other

Cat Behavior

Litterbox trained?

Yes No

Does this cat show aggression toward any of these? (describe if so)

Other cats

Dogs

Children

Other

Is this cat destructive? If so, please explain

Dog Behavior

Housetrained?

Yes No

Partially / has accidents? (explain)

How long does this dog stay alone at home?

When left alone, does this dog: (check all that apply)

Barks a lot Cries Destroys things Urinates / defecates Digs

Other (when left alone)

This dog is afraid of (thunder, fireworks, etc.)

When playing, does this dog: (check all that apply)

Jumps Growls Barks Nips Bites

Other (when playing)

How is this dog on a leash? (check all that apply)

Easy Pulls slightly Pulls hard Bites at leash

Dog's favorite type of toys

Commands this dog knows

Has this dog attended any obedience training?

Yes No

If yes, where?

Has this dog been around children?

Yes No

If yes, children's ages

How is this dog when meeting strangers? (check all that apply)

Friendly Barks Snaps Growls Afraid

Does this dog chase (or try to chase): (check all that apply)

Cats / small animals Other dogs Bikes Cars Joggers Livestock

Other (chasing)

Has this dog ever attacked or harmed another domestic animal?

Yes No

Has this dog ever shown aggression (with people or animals) involving: (check all that apply)

Toys Food Disturbed when sleeping Approached / reached toward

Agreement

By submitting this form you agree that all of these statements are true to the best of your knowledge. You certify that this pet is owned by you and understand that if it is not, you may be subject to legal action. You acknowledge that you are surrendering rights of ownership to Anderson Humane Society, Inc.

I have read and agree to the statement above. *

Type your full name as your signature *

Today's date is recorded automatically when you submit.

A non-profit society dedicated to serving the homeless and abandoned animal population of Anderson County, Kentucky.

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Visit Us

Adoption Center
1410 Versailles Road
Lawrenceburg, KY 40342

P.O. Box 494
Lawrenceburg, KY 40342

Reach Us

502-839-8339

president@andersonhumane.org

Hours
Mon–Fri: 9:00AM – 3:30PM
Sat: By Appointment Only
Closed Sundays & Holidays

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