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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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?YesNoREGISTRATION 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?CuddlerIndependentAffectionateTell us how your dog gets along with others:GOOD WITH CHILDREN?YESNOGOOD WITH OTHER DOGS?YESNOGOOD WITH CATS?YESNoIS YOUR DOG COMFORTABLE AROUND STRANGERS?YESNOHAS THIS DOG EVER BITTEN ANYONE?YESNOIS HE OR SHE DESTRUCTIVE?YESNODOES YOUR DOG DEMONSTRATE ANY ANXIETY WHEN LEFT ALONE?YESNOPLEASE 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 SPAMTRANSFER 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.