Surrender

1. CONTACT INFORMATION

Name*

First

Last

Address*

Street Address City State / Province / Region Postal / Zip Code

Home Phone:*

Mobile Number*

Email*

Date of Birth*

Best time to call*

AM

PM

Do you own a Mastiff (aka English Mastiff)? *

Yes

No

Note: If you answered “no” to the last question above because you own another type of Mastiff breed, please do NOT complete remainder of the form below. Great Lakes Mastiff Rescue only accepts Mastiffs (aka English Mastiffs or Old English Mastiffs) in the rescue program. Please check the links section on our website to find the appropriate breed-specific rescues in your region or send us an email with a brief description of your dog and the type of breed.

2. YOUR MASTIFF

Mastiff’s Name:*

Mastiff’s Gender:*

Age:*

Date of birth:

Mastiff’s Height (at shoulder):*

Mastiff’s Weight:*

Mastiff Color:*

Fawn

Apricot

Brindle

Spayed/Neutered:*

Yes

No

Unknown

Date of most recent vaccinations:

Is Mastiff up-to-date on heartworm preventative?*

Yes

No

Most recent heartworm preventative given:

Date of Most Recent Heartworm Test:

Heartworm test results:*

Positive (+)

Negative (-)

Unknown

Is Mastiff up-to-date on vaccinations?*

Yes

No

Date of Most Recent Vaccinations:

Is Mastiff up-to-date on rabies?*

Yes

No

Date of Most Recent Rabies

Is your Mastiff in need of immediate medical treatment?*

Yes

No

Date of Last Fecal Test:

If your dog is in need of medical attention, please describe:*

Please list all chronic illnesses that your Mastiff suffers and any required medications:*

How long have you owned your Mastiff?*

Is your Mastiff obedience trained?*

Yes

No

How many times of day is your Mastiff fed?*

How much for each feeding?*

Brand of food:*

Is your Mastiff good with children ages 0-5?*

Yes

No

Is your Mastiff good with children ages 5-10?*

Yes

No

Is your Mastiff good with children ages 10-18?*

Yes

No

Is your Mastiff good with small dogs?*

Yes

No

Is your Mastiff good with large dogs?*

Yes

No

Is your Mastiff good with cats?*

Yes

No

Unknown

Is your Mastiff good with birds?*

Yes

No

Unknown

Is your Mastiff good with livestock?*

Yes

No

Unknown

Is your Mastiff good with wildlife?*

Yes

No

Unknown

Is your Mastiff housebroken?*

Yes

No

Is your Mastiff crate trained?*

Yes

No

Reason for surrendering your Mastiff:*

Please describe your Mastiff and its behavior in detail:*

Has your mastiff ever bitten (either human or another animal)?*

Yes

No

If yes, please describe event in detail:

Has your Mastiff ever shown any aggressive, violent, or inappropriate behavior towards either a human or another animal?*

Yes

No

If answer is yes, please describe event in detail:

3. BREEDER/PET STORE INFORMATION

Did you acquire your Mastiff from a breeder?*

Yes

No

Breeder’s Name:

Breeder’s Kennel Name:

Breeder’s Address and Phone Number:

Did you acquire your Mastiff from a pet store?*

Yes

No

Pet store name and location?

5. VETERINARIAN INFORMATION

Please contact your veterinarian to authorize release of your pet’s records to Great Lakes Mastiff Rescue so that we may contact them to request copies.

Veterinarian Name:*

Clinic Name:*

Clinic Address:*

Clinic Phone Number:*

6. SIGNATURE

How did you hear of Great Lakes Mastiff Rescue?

I/We certify the information contained in this application is true and correct:*

Yes

No

Date of Submission:*

Your Name (Digital Signature):*