Surrender Form and Agreement Surrender Form and Agreement Your InformationName First Last Cell Phone*Home PhoneEmail Address NAME OF SPOUSE (TYPE NONE IF IT DOESN'T APPLY): SPOUSE CELL PHONE (TYPE NONE IF IT DOESN'T APPLY): *SPOUSE HOME PHONE (TYPE NONE IF IT DOESN'T APPLY): *Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country REASON FOR RELEASE OF DOG TO BICHON FURKIDS RESCUE: BREED (NOTE PUREBRED OR MIX): DOG'S NAME: AGE (DATE OF BIRTH IF KNOW): COLOR AND MARKINGS: HEIGHT AT SHOULDER: WEIGHT: AGE: Spayed or Neutered? Yes No REGISTRATION NUMBER: MICROCHIP NUMBER: NAME, ADDRESS AND PHONE NUMBER OF YOUR VETERINARIAN:BRAND NAME AND TYPE OF FOOD YOU HAVE BEEN GIVING YOUR DOG:HOW OFTEN DO YOU FEED YOUR DOG AND WHAT AMOUNT OF FOOD DO YOU GIVE WITH EACH SERVING?IS YOUR DOG HOUSEBROKEN? IF NOT, EXPLAIN:DOES YOUR DOG LIKE TO RIDE IN THE CAR? PLEASE EXPLAIN:DOES YOUR DOG GO FOR WALKS? PLEASE EXPLAIN THE WALKING SCHEDULE:WHICH OF THESE BEST DESCRIBES YOUR DOG? Cuddler Independent Affectionate Tell us how your dog gets along with others:GOOD WITH CHILDREN? YES NO GOOD WITH OTHER DOGS? YES NO GOOD WITH CATS? YES No IS YOUR DOG COMFORTABLE AROUND STRANGERS? YES NO HAS THIS DOG EVER BITTEN ANYONE? YES NO IS HE OR SHE DESTRUCTIVE? YES NO DOES YOUR DOG DEMONSTRATE ANY ANXIETY WHEN LEFT ALONE? YES NO PLEASE EXPLAIN ANY NEGATIVE BEHAVIORS RELATED TO THE QUESTIONS OF HOW YOUR DOG GETS ALONG WITH OTHERS, IS ANXIOUS OR DESTRUCTIVE OR IF HE/SHE HAS EVER BITTEN ANYONE.OVERALL, DESCRIBE YOUR DOG'S HEALTH. HOW OFTEN DO YOU GO TO THE VET AND FOR WHAT PURPOSE?DATE OF LAST VETERINARY VISIT: DATE OF LAST RABIES IMMUNIZATION: DATE OF LAST HEART WORM TEST: DATE OF LAST DHLPP: OTHER COMMENTS YOU'D LIKE US TO KNOW ABOUT YOUR DOG.PLEASE TYPE THE WORDS NOT SPAM WITH ONE SPACE BETWEEN THEM IN THE BOX TO THE RIGHT: NOT SPAM TRANSFER OF OWNERSHIP AND SURRENDER AGREEMENTBY SUBMITTING THIS FORM, I, THIS AGREEMENT TO TRANSFER OWNERSHIP("AGREEMENT") IS ENTERED INTO ON THIS DATE: acknowledge that I am the owner of the dog and am fully authorized to enter into this Agreement. I proclaim that the information provided on this form is accurate and I understand that Bichon FurKids Rescue will evaluate my dog prior to accepting my dog. At that time, I will hereby permanently and irrevocably transfer ownership of this dog to Bichon FurKids Rescue. By executing this Agreement, I acknowledge that I am irreversibly relinquishing to Bichon FurKids Rescue, any and all rights, title, and ownership that I had or may have had with respect to this dog.