EmailMe Form - HUSKY RESCUE WA - Surrender & Rehoming Application

Date

DD / MM / YYYY

Name *

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone *

Mobile

Email *

Name of Dog:

Sex of Dog:

Male

Female

Age of Dog:

Dog's Coat colour

Dog's Eyes Colour

Brown

Blue

Bi eyed

Is the Dog sterilized/de-sexed?

Yes

No

Is the Dog Vaccinated?

Yes

No

Due Date of next vaccination:

Has the dog been wormed:

Heartwormed

Intestinal wormed

No

Date they are Due?

Is the Dog Micro Chipped?

Yes

No

Micro Chip Number

Is the Micro Chip in the owners/your name?

Yes

No

If NO can you prove you own the dog?
(registration & or Healthcare documents)

Yes

No

Is the dog registered?

Yes

No

If Yes with what Council?

Are You the Dog's first owner?

Yes

No

If NO Please explain where and when you got the dog:

Reason for Re-homing the dog: *

What is the Dog's obedience level?

High

Medium

Low

Uncontrollable

Is the dog :

Please tell us about the dog's behavior around or level of exposure to children: *

How is the dog's behaviour around other animals?
Please explain: *

What is the Dog's current Diet? *

Are there any known medical conditions/special needs?

Yes

No

Unknown

If YES please explain & list any medication the dog is taking:

Any previous Incidence of Aggression?

Yes

No

If YES to above please describe:

Other Relevant Information you can provide to help in the re homing of your dog:

Can you continue to care for your dog until a home is found?

Yes

No

If NO please note we have a limited amount of foster families and we do not have a shelter.

Items Surrendered with the Dog:

Photo 1:

PLEASE ATTACH CURRENT PHOTOS AS THIS GREATLY ASSISTS IN FINDING A NEW HOME.

Photo 2:

Photo 3:

Signed Surrender Application:

This can also be signed at collection of the dog or emailed to you.

I/We agree to provide Husky Rescue WA with all veterinary documents in our possession and if micro-chipped to sign the Australian Animal Registry Change of Ownership form..
I/We agree the above information provided is true and correct to the best of my/our knowledge..
I/We agree to advise Husky Rescue WA immediately if I/we decide to withdraw our intention to surrender the dog.
I/We understand that Husky Rescue WA will endeavour to find a new home but does not guarantee that one will be found for my/our dog. Until a suitable home is found,
I/we are still responsible for our dog. *

AGREE