OWNER SURRENDER QUESTIONNAIRE

  


Please answer the following questions to the best of your knowledge.  The more information we have on your pug, the better we can match it with a foster home and potential adoptive home. 

Legal Owner's Name: 

Email Address: 

Phone Number (Day):  (Evening):  Cell Phone: 

Home Address:  

City:  State:  Zip Code: 

Your Pug's Name: 

Is your dog a purebred Pug or a mix?:    Purebred     Mix  

Male or female?:    Male     Female

Spayed or Neutered?:     No     Spayed     Neutered     Unknown    Please select your answer

If intact, are you willing to have your pug spayed or neutered?:     Yes     No    Please select your answer

Dog's Age and/or Date of Birth:

Is your pug current on all vaccinations?:    Yes     No    Please select your answer

DO YOU HAVE A CURRENTLY VALID RABIES VACCINATION CERTIFICATE AND WHEN DOES IT EXPIRE?:   
  Yes     No    Please select your answer  Expiration of rabies:

Is your pug on Heartworm preventative?:    Yes     No    Please select your answer

When was your pug last tested for Heartworm?:

Does your pug have a microchip?:    Yes     No    Please select your answer

Where did you get your pug from and how long have you had him/her?: 

If from a breeder, the breeder's name and/or kennel name:

EXACTLY where do you keep the pug when you are not home? (Please be specific, i.e., loose outside, outside in a kennel, indoors free, indoors in a crate, in the laundry room, etc.:

Is this an indoor or an outside pug?:    Indoors     Outside    Please select your answer

EXACTLY where does your pug sleep at night?:

Is your pug reliably housebroken?:    Yes     No    Please select your answer

Does your pug mark in the house?:    Yes     No    Please select your answer

Is your pug crate trained?:     Yes     No    Please select your answer

Has your pug ever been left loose in the house while no one was home?:    Yes     No    Please select your answer

Does your pug panic when left alone (i.e., barking, pawing at blinds or under doorways, scratching on doors, escaping, vocalizing and otherwise manifesting high [separation] anxiety)?:    Yes     No     Sometimes    Please select your answer

Has your pug had ANY formal (obedience) training/classes?:    Yes     No    Please select your answer

If yes, where, when and with whom?:

Is your pug well socialized (i.e., FREQUENTLY taken OFF its home property and exposed to strangers, strange dogs, strange things and public places?:    Yes     No

Does your pug walk well on a leash or does he/she pull?:    Yes     No, pulls   Please select your answer

Has your pug been exposed to the following? (Please check) How does your pug get along with each? If your pug has had exposure, please elaborate on how he/she behaves with each:

Kids    

Toddlers (4 and under)    

Cats    

Other Dogs    

If you had to use TWO of the following words ONLY, how would you describe your pug?

Submissive
Dominant
Affectionate
Aggressive
Fearful
Confident
Skittish/Shy
Nervous/Neurotic

Does your pug bolt, jump or escape often?:    Yes     No    Please select your answer

Does your pug have any health issues we should be aware of, including allergies?:    Yes     No    Please select your answer

If yes, please explain:

Is your pug on any medications?:    Yes     No    Please select your answer

If yes, please explain:

Was your pug ever diagnosed with or treated for Valley Fever?:    Yes     No    Please select your answer

If yes, please explain:

Does your pug have hip dysplasia or arthritis?:    Yes     No    Please select your answer

Does your pug have any behavioral issues, such as food aggression?:    Yes     No    Please select your answer

If yes, please explain:

Has your pug ever bitten anyone?:    Yes     No    Please select your answer

Has your pug ever attacked another dog?:     Yes     No    Please select your answer

Does your pug know how to swim?:    Yes     No     Unknown    Please select your answer

Does your pug show a preference for either men or women?:     Yes, Men     Yes, Women     No    Please select your answer

Why are you surrendering your pug? 

How much longer can you keep your pug while we locate a suitable foster home?:

What does your pug eat, and how much?

What is the name, address and phone number of your pug's veterinarian?:

What is the date (month and year) of your pug's last vet visit and the reason for the visit?:

If you have access to a digital camera, it would be very helpful if you could Email arizonapugrescue@yahoo.com several photos taken outdoors during the day of your pug. We would prefer a face (front) shot, a standing (side) shot and a sitting (front) shot if possible. JPEG attachments are best.

When you have finished filling out this form, click "SUBMIT" to send your form to us. 
We will be in touch with you shortly after we have had an opportunity to review the information that you have provided.
Thank You