I ____________________ on this day _____/_____/_____/ relinquish ownership of the Shetland Sheepdog known as ____________ AKC#______________ to Sheltie Rescue of Georgia Inc, with the exception of any and all summons, law suits, and damages caused by the above mentioned dog. I also agree to release any and all paper-work pertaining to the above mentioned dog, (health records, AKC. papers etc.) to Sheltie Rescue of Georgia Inc. To help with the adoption process I agree to fill out this questionnaire to the best of my knowledge.

NAME________________________________ADDRESS_________________________

CITY____________________________STATE_____________ZIPCODE__________

HOME PHONE # (_____)______________ WORK PHONE # (_____)______________

E-MAIL ADDRESS____________________________

SIGNED___________________________________ DATE________/_______/_______

Please explain why you are giving up ownership of this dog.

________________________________________________________________________

________________________________________________________________________

Please give name, address and phone number of the veterinarian that has cared for this dog

________________________________________________________________________

________________________________________________________________________

What is the age of this dog? ______ yrs. ____mo. date of birth _____/_____/_____

Is this dog house broken? Y N

Has this dog ever bitten anyone? Y N If yes please explain.

Is this dog up to date on all of it’s shots? Y N

Date of last worming? _____/______/______

Date of the last heart worm check? _____/_____/____. What were the results ? Positive or Negative

What heartworm preventative has this dog been using?____________________________

Date of last dose of heartworm preventative. _____/_____/_____

Has this dog ever had Lymes Disease? Y N

Does this dog have any medical problems? Y N If yes please explain what they are and what course of treatment is being used to correct the problem.

Has this dog had any formal obedience training? Y N

What type (Brand Name and Variety) and how much dog food is this dog being fed?_______________________________________________________________

Has this dog ever been bred or used for stud service? Y N

Is this dog spayed/neutered? Y N

Where did you get this dog from? (Pet store, breeder, shelter, etc.) name of breeder or pet store also include the address.___________________________________________________________

How long have you owned this dog?_________________________________________

Where is this dog normally kept?___________________________________________

When outside how is this dog confined? fenced yard, walked on a leash, cable run, kennel, or allowed to roam.

When indoors how and where is this dog kept? Free run of the house, confined to a room, crated up or tied up.

Where does this dog sleep at night____________________________________________

Is this dog destructive when left alone? Y N If yes will it chew-up objects on the floor, chew furniture, carpets or flooring, door frames or wood work? Please circle all that apply.

Has this dog ever lived with children? Y N If yes what ages__________________________

Has this dog ever shown aggression towards children, men, women, strangers? Y N if yes please explain.

Does this dog play rough or show aggression towards other animals? Y N if yes please explain________________________________________________________

How does this dog act when riding in a car?_____________________________________

Has this dog been bathed and or groomed regularly? Y N

How does this dog react when you have strangers come to your home? Aggressive, barks a lot, runs away, friendly, jumps on them, could care less? Circle all that apply.

Have you tried to find a home on your own for this dog? Y N

How did you hear about Sheltie Rescue of Georgia? ________________________________

Any other information that could help place this dog (likes or dislikes etc.).