Owner Surrender Questionnaire

Due to the overwhelming number of incoming strays, sick and injured animals coming from our community in West Memphis, Arkansas, the shelter is not able to accommodate owner surrenders, and we have had to initiate surrenders by appointment only. If applicable, you will need to place your pet into another home yourself and use the animal shelter as a last resort. If you’re unable to place your pet yourself into a new home, we need some information about you and your pet(s).

Photos of the pet(s) must accompany this form and should be a good face shot, body shot and a distance shot. Please try to get the best photos possible.

*Once we receive the questionnaire, photos and veterinary history on your pet we will begin working diligently to find a home for your pet. As space opens in our kennels you will be notified when to bring your pet(s) to the West Memphis Animal Shelter, this process could take up to 2 weeks or longer in some cases, before call but less when we get an opening.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Contact

(###)

###

####

Secondary Phone Contact

(###)

###

####

Animal No. 1 for Surrender

List the following information below. Name of Pet, Breed, Color/Markings, Age or Date of Birth, Sterilization Status.

Animal No. 2 for Surrender

List the following information below. Name of Pet, Breed, Color/Markings, Age or Date of Birth, Sterilization Status.

Animal No. 3 for Surrender

List the following information below. Name of Pet, Breed, Color/Markings, Age or Date of Birth, Sterilization Status.

Does your pet tend to bite or snap at people or other animals?

If yes, did the bite cause the skin to break or bleed?

How long have you owned this pet?

Days, weeks, months or years

Including your home, how many homes has this pet had that you know of?

How did you acquire this pet?

Breeder, found stray, family member, rescued, etc.

Describe the family types that your pet has lived with?

(example-Women only, men only, family unit (adults & children)

Describe the animal behavior with the children & their ages?

Would you recommend placing this pet in a new home with children?

Yes or No, if no, why?

What other animals has your pet lived?

List the types of animals this pet has been exposed to and their interactions. Be specific.

Would you recommend placing this pet in a home with other dogs?

Yes or No, if no, why?

Would you recommend placing this pet in a new home with cats?

Yes or No, if no, why?

Where was your pet kept when no one was at home?

Indoors-free roam, kenneled, etc, Outdoors-free roam, kenneled, cage or pen, chained up in the yard.

Where does your pet sleep at night?

In the family bed, other area of the home, outside, doghouse, etc.

Was this pet indoors only, indoors/outdoors or strictly an outdoors animal?

Has this pet ever lived at the end of a chain or tie out cable for extended periods of time?

Yes or No, if yes, why?

Did your pet escape your yard?

Fence condition-Good/Fair/Poor; type of material-Chain Link/Fence/Other type. How tall was fencing? Did your pet dig under, jump over or climb over?

Is your pet housebroken or litter box trained?

100%, partially, accidents on rare occasions, etc.

Is your pet descructive?

All the time, sometimes when bored, only when left alone or for extended periods of time, other (be specific)

When your pet is home alone, does he/she annoy the neighbors or delivery personnel?

Barking, charging the fence, chasing passerbys, etc?

What type of food have you been feeding this pet?

Brand of food, prescription food, table food or scraps, etc.

Does your pet raid the garbage can/trash bin or steal unattended food from the table or counters?

Does your pet steal food from your hand?

Has your pet had any training?

Basic commands, professional training, obedience classes

Does your pet jump on people when greeting them or for other reasons?

Does your pet have a favorite toy or bedding?

Yes or No, if yes, what?

Describe your pet's behavior inside a vehicle?

Is your pet protective or possessive of anything?

If yes, what and how aggressive is the pet of that object?

Please list any and all things that your pet is frightened of?

Visually afraid of something or hearing noises or bangs.

Is your pet spayed (female), neutered (male) or intact?

A surgery to stop reproduction.

List the name or clinic that performed the vaccines, surgery

Veterinarian Name & Phone Number, Date or year of surgery/vaccines.

Is your pet up to date on core vaccines (parvo, distemper, etc.), rabies vaccination?

Rabies can only be given by a State licensed Veterinarian.

If a dog, is he/she on monthly heartworm prevention? When was the last time the dog was tested for heartworms? Results? Positive or Negative

Test can only be performed by a licenced veterinarian.

If a cat, has he/she been tested for Feline Leukemia or Feline Immunodeficiency Virus.

These viruses are contagious to other cats.

Has your cat been declawed?

Front only, back only or all four? If yes, why?

Anything else we may need to know about your pet that we may have missed?

Thank you for taking the time to complete this information necessary for our knowledge to help in rehoming your pet into the most appropriate new family or rescue group.

Owner Surrender Questionnaire

If you have any questions, please feel free to contact us at:

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