Owner Surrender Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.We are dedicated to finding the best, safest and the most appropriate home for your animal. Undesirable behaviors and medical issues don't necessarily create problems in placement, however, NOT disclosing those problems does. Dishonest or incomplete answers can undermine the safety and happiness of both your dog and the new adopting family. If there is anything on this form that you are unclear about or that you are uncomfortable answering, please call us directly at 719-357-6913. If you have multiple animals, please submit a separate form for each animal. Name *FirstLastID Photo * Drag & Drop Files, Choose Files to Upload Address *Address Line 1Address Line 2CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryEmailPhone #Pets Name *Pets Species *Breed *Coloring *Weight *Date of Birth *Is your pet microchipped? Chip number? *How/where did you acquire your dog *How long have you owned this dog? *Sex *MaleFemaleSpayed/Neutered *YesNoIs your pet house broken? *Is your pet crate trained? *How does your pet do in a vehicle? *Is your pet current on vaccines (including rabies)? Please provide veterinary records. *Has your pet been on heartworm prevention? If yes when was it last given? *Has your pet been on flea and tick prevention? If yes, when? *Is your pet on any medication? If yes what meds? *Does your pet have any allergies? If yes what? *Has you pet been heartworm tested? If so, what were the results *Animals TempermentHyperMellowIn-betweenIs your pet very vocal? If so when (when left alone, general talker....) *Has your pet ever bit anyone? Did the bite occur in the past 10 days? If so, please explain *Is your pet good with children? *YesNoIs your pet good with dogs? *YesNoIs your pet good with cats? *YesNoIf no to any of the above questions, please explain *How does your pet respond to walking on the leash? *Does your dog escape? if so how?Digsjumps/ climbs fenceopen gatesotherDoes your pet chase?CarsBicyclesMotorcyclesKidsLife stockDoes your pet have any guarding/ aggressive issues? (food, toys, etc} If so please explain *Has your dog injured another animal? If so please explain *Does your pet have a preference with men or women? please explain behavior *Does your pet have any medical issues? If so please explain (copy) *What is your reason for surrendering your pet?BehaviorMedicalMovingDivorseOtherPlease explain reason for surrender *Lastly, any other details to help find the best placement for your pet *You understand and agree to the following: *You are the legal owner of the animal you are relinquishing. I, undersigned, owner or having control of the animal described above, hereby give ownership of said animal to White Rose Sanctuary to be placed for adoption. I agree to make all veterinarian records for said animal available to the rescue. I certify that, to my knowledge, this animal has not bitten or scratched anyone in the past fourteen days or been exposed to rabies. I have answered these questions truthfully and to the best of my knowledge. Please take four good quality, well-lit photographs of your pet and submit them here or email them to us at wolff@wrsanctuary.com with your name and the animal's name in the subject of the email. Videos are also welcome. Pet Photos/ Videos * Drag & Drop Files, Choose Files to Upload Signature * Clear Signature Printed Name *Date / Time *DateTimeSubmit