Revised 05/12/2011

SURRENDERED PET INFORMATION FORM

In an effort to guide us in placing your dog in the best possible new home, please complete this questionnaire as completely and honestly as possible.

(Required fields are marked with a red asterisk.)

E-mail Address: * First Name: * Last Name: * Address1: * Address2: City: * State: * AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Zip Code: * Phone Number (cell): Phone Number (home): * Phone Number (work): NJSRN is a non-profit 501(c)(3) charitable organization that relies on donations to help Miniature Schnauzers in need. Your donation will help us to offset the cost of caring for our rescued dog and allow us to continue this valuable work. Donations may be made on our website through PayPal or by check made payable to NJSRN. Checks may be given to the NJSRN member when you surrender your dog, or you can mail your donation to our official mailing address at PO Box 36, Fanwood NJ 07023.   DONATION, if any (not required, but very much appreciated): * Name of Dog: * AKC Registered Name and Number (if known): Gender: * female male Spay/Neuter Status: * dog has been spayed or neutered dog is intact Date of Birth (if known): Approximate Age: Description: * Size: * Weight: * Color: * black black & silver salt & pepper other Other Color: Ears: * cropped natural Tail: * docked natural Breed: * purebred Miniature Schnauzer Schnauzer mix (non-shedding) Schnauzer mix (shedding) Mixed with? (If known.) Ever been bred? (If known.) * yes no unknown If yes, when? Most recent vaccinations (date and type): * Where did you get this dog? * casual breeder or show breeder pet shop shelter rescue group friend or relative gift stray other Explain (include name of breeder, shelter, rescue group, or other, if known): ... on (approximate date): * ... at (approximate age): * If this dog was FOUND, please give location and date: Reason for rehoming your Schnauzer: * Do you have a timeframe in mind for surrendering your Schnauzer? * yes no Please explain when you would like to surrender your Schnauzer: Veterinarian First Name: Veterinarian Last Name: Clinic Name: Clinic Address1: Clinic Address2: Clinic City: Clinic State: AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY -Terr.- AS FM GU MI PR VI Clinic Zip Code: Clinic Phone Number: Is this dog housetrained? * yes no unknown Is this dog crate trained? * yes no unknown Is this dog leash trained? * yes no unknown Does this dog get along with other dogs? * yes no unknown Does this dog get along with cats? * yes no unknown Does this dog ride well in a car? * yes no unknown Does this dog get along with children? * yes no unknown Has this dog lived with children? * yes no unknown If yes, what age(s)? Does your Schnauzer have any known medical or behavioral problems? * yes no unknown If yes, please specify: Has this dog ever bitten or shown any aggressive tendencies? * yes no unknown If yes, to whom and under what circumstances: Is this dog possessive of toys, food, or his people? * yes no unknown If yes, please explain: Has this dog lived with other animals? * yes no unknown If yes, what type(s)? Approximately how many hours a day is your Schnauzer alone? * Is this dog a house pet or an outside dog? * house pet outside dog How frequently must he go outside? * How does he tell you he needs to go outside? * How do you exercise your Schnauzer? * walks kennel run fenced yard allow him to run loose Does this dog walk on a leash without pulling? * yes no somewhat Walks best on? * harness collar During the day, is this dog happiest in ...? * house crate outside At night, is this dog happiest in ...? * your bed his or her own bed house crate outside Does this dog know how to go up and down stairs? * yes no unknown Has this dog been obedience trained? * yes no unknown Who had the major responsibility for training this dog? How does this dog respond to commands? * excellent good fair poor when he wants to Please describe the personality and temperament of your Schnauzer: * What food do you feed your Schnauzer? * Quantity and frequency: * Does this dog need a dental cleaning? * yes no unknown Is your Schnauzer on heartworm preventative? * yes no unknown If yes, what type? daily monthly Date last given? How long since his last grooming? * Please describe, in your opinion, the best type of home or home environment for this dog: * The undersigned warrants that he/she is the owner or authorized agent for the owner and that this dog is in good physical condition, has no diseases or infections, is not vicious, and does not have a history of biting or attacking people. Any exceptions to these statements must be explained in response to the question above regarding medical or behavioral problems. ALL STATEMENTS MADE IN THIS PET INFORMATION FORM ARE TRUTHFUL TO THE BEST OF MY KNOWLEDGE.   Verification (read the statement above and type your name here): * Verification Code: Enter Verification Code: * * Required