Rehoming / Owner Surrender Owner Surrender/Rehoming Form Rehoming Application request Step 1 of 5 - Personal Information 20% You The Owners Full Name* First Last Phone*Email* Address* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zipcode Where are you located? I am looking to Rehome a:*What kind of PetDogCatPlease indicate what type of pet you are looking to rehome.About your Pet*Animals NameBreedApprox WeightAge Information the petWhere did you obtain this Pet?* Pets PersonalityBio*Is your Pet good with?* Cats Small Dogs Big Dogs Children Other Animals None or unknown These questions are for our information and foster placement please be honest with your answers. Does your Dog have a bite History?*Please SelectYesNoAbout it's bite histroy*Please give details and date, and what triggered the behavior. Medical QuestionsIs the Animal Spayed or Neutered?* Yes No Do you have Copies of it's vaccination records, and are they up to date?* Yes No Photos/Documents of Vaccination Records Drop files here or Select files Accepted file types: jpg, png, pdf, gif, jpeg, , Max. file size: 50 MB. Please upload any photos or PDF scans of your dogs vaccination records and spay or neuter certificate. Does it have a Microchip?* Yes No We will need to have you transfer ownership for our registration. Does your Animal have special medical needs?* Yes No Medical needs such as diabetic, epileptic, food allergies, any incurable dieses that need to be treated to maintain healthy quality of life. Medical Needs:* Reason for Wanting to Rehome your Animal.*Explain your reason(s) for wanting to rehome your pet.Photo of your Animal* Drop files here or Select files Accepted file types: jpg, png, pdf, gif, jpeg, , Max. file size: 50 MB, Max. files: 3. Please upload a photo of your Animal Do you agree to the following* I agree to the followingI hereby certify that I am the rightful owner/keeper/caretaker/custodian of the animal(s) who is/are the subject of this Owner Surrender Form, hereinafter referred to as “the animal.” I hereby surrender any and all property rights of the animal. I release and discharge Hearts 4 Paws from any and all claims, obligations, liabilities, and causes of action whatsoever arising out of or relating to the ownership, possession, or disposition of the animal(s) and agree to hold harmless Hearts 4 Paws from and against any and all such rights claims, obligations, liabilities and causes of action which may be asserted by other parties. I certify that no other person has a right of property to the animal. I understand that by surrendering my property rights to the animal, the animal may be transferred into the custody of Hearts 4 Paws. I also hereby certify that the animal has not bitten or scratched a human or another animal within the past 10 days. I understand that once I relinquish the animal, the animal will not be available to be returned. I further certify that I have read and understand the terms of this Owner Surrender Form.Owner's SignatureTo be Signed at time of Surrender.Todays Date* MM slash DD slash YYYY For legal records.Donation at time of surrender*Please enter a number greater than or equal to 200.Minimum 200 dollar donation required for medical spaying and Neutering of the Animal.Donation at time of surrender*Please enter a number greater than or equal to 100.Minimum 100 dollar donation required.Are you a Robot? Δ
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