Personal info:

Name:

Email Address:

Phone:

Information on shelter:

Organization name:

Organization Phone if different from above:

Contact Person if other than yourself:

Address:

City/State/Zip:

Hours of Operation

Will dogs be spayed or neutered prior to placement with rescue?

Our board voted recently that we must know the heartworm status of dogs before we can accept them into our program. A positive test result will not result in automatic dismissal from consideration; however, our budget does limit the number of hw + dogs we can treat.

Will dogs be Heart Worm tested prior to placement with rescue?

What vaccinations do dogs receive prior to placement with rescue?

Does the shelter charge a rescue fee?

If yes, what is the amount of the shelter fee?

Information on the Dog(s):

Pictures (in JPEG format) of the dog(s) should be attached below. Email pictures to Bridgett Miller.

Dog #1 Name:

Dog #1 ID #:

Dog #1 Age:

Dog #1 Sex:

Dog #1 Pure-bred:

Dog #1 HW Check:

Dog #1 Kill Date:

Dog #1 Comments:

Dog #2 Name:

Dog #2 ID #:

Dog #2 Age:

Dog #2 Sex:

Dog #2 Pure-bred:

Dog #2 HW Check:

Dog #2 Kill Date:

Dog #2 Comments:

Dog #3 Name:

Dog #3 ID #:

Dog #3 Age:

Dog #3 Sex:

Dog #3 Pure-bred:

Dog #3 HW Check:

Dog #3 Kill Date:

Dog #3 Comments:

Dog #4 Name:

Dog #4 ID #:

Dog #4 Age:

Dog #4 Sex:

Dog #4 Pure-bred:

Dog #4 HW Check:

Dog #4 Kill Date:

Dog #4 Comments:

Dog #5 Name:

Dog #5 ID #:

Dog #5 Age:

Dog #5 Sex:

Dog #5 Pure-bred:

Dog #5 HW Check:

Dog #5 Kill Date:

Dog #5 Comments:

Other Comments About These Dogs:

How did you hear about Southern States Rottweiler Rescue, Inc.?

We reserve the right to refuse acceptance of any Rottweiler. Acceptance is based on many criteria, one of which is space availability. If you are out of our area, we will pass on your surrender form to another rescue.

I understand that the information contained in this form might be passed on to another rescue.

Additional comments:

I certify that the information provided on this form is true & correct. I understand that an physical evaluation of the dog by an experienced rescue volunteer will be required before we accept surrender. If upon inspection we find that information contained in this surrender form to be false, we retain the right to turn down acceptance of the surrender at anytime during the evaluation.

Signature (re-type email address):