Dog Surrender Questionnaire "*" indicates required fields Step 1 of 7 14% Owner DetailsFull Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mobile Phone*Email* Dog's detailsDog's name* Dog's Age* DOB DD slash MM slash YYYY Breed* Approx. weight Sex* Female Male Desexed* Yes No Unsure Microchipped* Yes No Unsure Microchip Number If microchipped, is the dog registered to the current owner?* Yes No Unsure Is the dog registered with your local council?* Yes No Unsure Last vaccination dateDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What was the vaccination for? Where did you get your dog?* Did you pay for your dog?* Yes No Unsure How old was your dog when you acquired him/her?* Please explain why you are surrendering your dog* Lifestyle and home lifeIs your dog allowed inside?* Yes No Sometimes Is your dog allowed outside?* Yes No Unsure Where does your dog prefer to spend most of its time?* Indoors Outdoors What sort of fenced yard do you have?* How high is the fence?* Did your dog ever get out?* Yes No If yes, did your dog* Jump out Dig out Climb out Other Unsure How did your dog get out*If your dog was escaping how often would this occur?* If your dog was escaping describe why you think the dog was doing this*What did it do when it was out?*When no one is home where is your dog kept?* What does your dog do as you leave the house?*What does your dog do when left home alone?*What does your dog do when you return home?*Where does your dog sleep at night?* How much time does your dog spend on his/her own?* Does your dog follow you from room to room when you are home?* Yes No Sometimes Do you have any other dogs?* Yes No Do you have any cats?* Yes No Do you have any other pets?* Yes No What sort of pet?* How does your dog interact with these other pets?*Which pet arrived in your household first?* How many adults and children live at home with the dog?If there's any children, please specify what age they are. If there's any children, does any of them play with the dog? Yes No If yes, does the dog Tolerate them Ignore them Walk away Hide from them Other Please give details*Has your dog met many children?* Yes No Unsure Has your dog met many adults?* Yes No Unsure Has your dog met many dogs?* Yes No Unsure Has your dog met many other animals?* Yes No Unsure Behaviour and temperamentHow active is your dog?* Very Moderately Not very Unsure How playful is your dog?* Very Moderately Not very Unsure How affectionate is your dog?* Very Moderately Not very Unsure Does your dog like to be patted / touched?* A lot Sometimes No Unsure Has your dog ever needed to be muzzled for any reason?* Yes No If yes, under what circumstances?*Has your dog ever been declared a Dangerous Dog?* Yes No Has your dog ever shown aggression towards a person?* Yes No If yes, please explain*Has your dog ever bitten a person?* Yes No If yes, please explain*Has your dog ever bitten another dog?* Yes No If yes, please explain*Does your dog travel well?* Yes No Does your dog vocalise excessively?* Yes No If yes, when and why?*Is there anything that may cause your dog to be nervous or fearful?* Yes No Please tick what triggers your dog* Storms Loud noises Fireworks Camera flashes Other dogs Other animals Other trigger Please specify what other things triggers your dog* How does your dog react?* FoodWhat do you feed your dog?* How many times a day is your dog fed?* Is your dog comfortable with people and animals being around when he/she is fed?* Yes No If no, what does the dog do in this situation?*Is your dog comfortable with other animals being around when he she is fed?* Yes No If no, what does the dog do in this situation?*Can you easily take food, bones, and toys from your dog?* Yes No If no, what is your dog’s reaction when you try to take such items?*TrainingHas your dog attended training or puppy classes?* Yes No If yes, please provide details of his/her training*What classes? How long ago? Where? What methods were used? e.g. treat training, etc. How well does your dog walk on a leash?* Walks well Pulls sometimes Pulls constantly Won’t walk Do you use any walking equipment? Head halter Body harness Choker Flat collar HealthHas your dog ever had any vaccinations?* Yes No Unsure If yes, when?Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What is the name of your current vet? What are the contact details for the current vet? When and why was the last time you took your dog to the vet?* Does your dog have any medical conditions/history that you are aware of?* Yes No If yes, please explain*Is your dog currently on any medication?* Yes No If yes, please explain*Please attach any copy of vaccinations/medical reportsMax. file size: 128 MB. Exercise and PlayHow often is your dog walked?* Daily Weekly Monthly Rarely Never How long does a walk last?* Where do you take your dog when you walk him/her?* Describe your dog’s reaction when he/she sees another dog whilst walking?* Do you regularly exercise your dog off-leash?* Yes No Do you let your dog sniff/play with other dogs (outside the home)?* Yes No What are your dog’s favourite kinds of games to play?* What are your dog’s favourite kinds of toys?* Is your dog rough/mouthy in play?* Yes No If yes, please describe:*GroomingHow often do you bath your dog?* Daily Weekly Monthly Rarely Never How often do you brush your dog?* Daily Weekly Monthly Rarely Never How does your dog behave when groomed?* Compliant Fusses but can control Scared Panics and cannot control Becomes aggressive Never tried Has your dog ever been professionally groomed?* Yes No Can you easily trim your dog’s claws?* Yes No Additional InformationPlease tell us anything else about this dog that you think future adopters would like to knowSurrender Fees*Please note that NRAS requests a surrender fee per animal. If your animal is older than 6mths and not registered, the surrender fee will also include the registration fee needed. Any additional health checks required will also be added to the surrender fee. I understand.*Correct info*If it is found that any of the above information you have supplied is incorrect NRAS reserve the right to pursue any monetary cost from you that arise from any incident/s I declare that all the information I provided is correct.*Signature*HiddenDate DD slash MM slash YYYY
