ID/Driver’s License # _______________________________________________________
Address _____________________________________________________________________
Mailing Address
City State
E-mail address __________________________________________________________________________________
Home/Cell Phone Number______________________
Other Contact Number _______________________
Reason for Surrender:
To your knowledge, has this animal bitten anyone within the past ten (10) days? YES NO
Dog Biographical Information:
Dog’s Name: _______________________________ Age: __________ Sex: Male Female Breed:
___________________________ Color: _______________________ Size:
lbs. I originally got my
dog from:
I’ve owned him/her for:
I would describe my dog as: A Family Dog For Adults Only One Person Dog
My dog currently lives with: Other Dogs Cats Other:
Does your dog get along well with these animals? Yes No
My dog goes outside to urinate and defecate: Always Sometimes Never
For how many hours at a time is he/she left alone? _____ Is he/she crate trained? Yes No
While I’m away from the house, my dog is kept:
Loose in the House Loose in the Yard Chained in the Yard In a Crate
In an Outdoor Kennel Restricted to One or Two Rooms
When left alone, my dog: (check all that apply)
Barks Chews Furniture Scratches on Doors or Windows Chews Personal Items
Defecates/Urinates in the House
My dog is afraid of: (check all that apply)
Strangers Loud Noises Thunderstorms Men Being Alone Children
Vet Visits Car Rides Other: ______________________________________________
Animal Control
Owner Surrender of Dog Form
Surrendering Owner’s Name ____________________________ Date ____________
My dog knows the following commands: (check all that apply)
Sit Lie Down Stay/Wait Heels on Leash Come
Most of the time, I would describe my dog as: (check all that apply)
Friendly Protective Affectionate Craves Attention Quiet Aggressive
Fearful Hyper Plays Rough Shy Playful Stubborn Destructive
Clingy/Needy Other:________________________________________________________
My dog was last seen by a veterinarian on: ____________ at _____________________________
Vet Practice / Vet’s Name
My dog: Is Spayed or Neutered [If not, will you pay to have it spayed/neutered? Yes No
Is Microchipped, ID#__________________________________ Is Current on Vaccinations
Has Never Been to a Veterinarian
Other helpful information about my dog [health concerns, medications, behavior, etc.]:
[A behavior questionnaire is included on the next page]
Please review and sign below acknowledging the following:
I am the owner of this animal or the owner’s representative acting upon the owner’s consent.
Animals with illness or contagious disease, animals with age-related problems, and animals that pose a
health or safety risk to people or other animals and cannot be handled safely are not candidates for our
adoption program and may be humanely euthanized. Arkadelphia Animal Control cannot guarantee
adoption or placement of any animal. Sometimes health, age, or behavioral problems present after
admission, or our veterinarian/staff discover them upon examination or evaluation. Animals may also be
humanely euthanized if appropriate housing and care are not available.
I understand that whether or not this animal is made available for adoption is at the discretion of the
Arkadelphia Animal Control and that if I have questions regarding the disposition of this animal, I should
ask them now.
My signature below reflects that I read and understand the above information and that I am releasing all
rights and claims for this animal to the Arkadelphia Animal Control.
Owner Name
Behavior Questionnaire
Key for Defining Dog Behaviors
Using the key provided, please describe how your dog behaves in the following circumstances.
Let a staff member know if you have questions.
Very Excited: My dog will bark, whine, and jump up on people and objects. My dog seeks out
activity and will chase people or things. My dog has a hard time calming down and
usually has to be removed from whatever is causing the excitement.
Excited: My dog will bark/whine and may jump up on people or objects but calms down quickly.
Happy: My dog is interested/polite. My dog doesn’t jump but wags his/her tail and approaches.
Indifferent: My dog is not interested and does not break away from whatever s/he may be doing.
Anxious: My dog appears interested and will approach. Ears are down and his/her tail will be
tucked but wagging. My dog looks guilty and may get worked up, urinate, and roll over. Scared:
My dog runs away from the situation and attempts to hide under or behind a table or
other object. My dog may eventually approach depending on the circumstances. Growls:
My dog growls in a low tone and may assume a stiff body posture.
Shows Teeth: My dog’s lips curl back so that the front teeth can be seen.
Snaps: My dog attempts to bite, but does not make contact with skin.
Nips: My dog bites, but does not bite hard enough to break the skin.
Bites: My dog bites, breaks the skin or tears clothing.
Barks: My dog is very vocal.
Don’t know: I am not familiar with how my dog would react in this situation.
Other: If none of the above apply, please explain how your dog would respond.
I or another family member enter the house:_____________________________________________________
A visitor enters the house: _______________________________________________________________________
Children who are visitors enter the house: _______________________________________________________
My dog sees a jogger or child on a bike: __________________________________________________________
I take a favorite toy or bone away from my dog: __________________________________________________
I take away food or a treat: _______________________________________________________________________
My dog is disturbed while sleeping: ______________________________________________________________
My dog sees another dog walking on leash: ______________________________________________________