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Owner Surrender Form

Please note the use of the Enter key will submit the form - use the mouse or Tab key to navigate the form fields to avoid accidentally submitting an incomplete form.

Please be advised before proceeding with filling out the following information, that SCMR requires all necessary vetting expenses be paid for by the owner, including but not limited to: bring up to date all shots, spay/neuter, dental, heartworm test.

If you prefer mailing the application instead of using the online submission method, you may complete the form below, print it, and mail it to SCMR at: SCMR; P.O. Box 2005; Chattanooga, TN 37409 . Downloadable PDF and MS Word versions of this form are now available.

Please tell us about you:

Owner name(s):

Home address:

Street address:
City, State Zip:

Mailing address (if different):

Street/P.O. Box:
City, State Zip:

Home phone:

Work phone:

Email address:

What is the best time and method to contact you?

Please tell us about the pet(s) you wish to surrender:

What is the breed of your pet?

Pet name(s):

Pet D.O.B. :

Pet age(s):

Sex:  Male  Female  Multiple pets (male and female)

If surrendering multiple pets (both male and
female), please specify the sex of each pet below:

Is the pet altered (spayed or neutered)? Yes  No

If surrendering multiple pets (some altered
and some not), please specify the spay/neuter
status of each pet below:

What is the weight of the pet? (If surrendering more than
1 pet, please provide weight for all pets.)

What is the color of the pet? (If surrendering more than
1 pet, please provide colors for all pets.)

Please describe any distinguishing marks:

Are registration papers available? Yes  No

Please provide any additional comments regarding registration papers below:

Provide contact information of Veterinarian below. SCMR will also require you to contact your Veterinarian and let them know we will be calling to verify the provided information, giving SCMR permission to get the needed information.

Name: Address: City, State, Zip: Phone Number:

Date of last vaccinations:

Heartworm check:

Is the pet currently on any medication?

What brand of food does the pet eat? How many times daily? What time? How much?

Where does the pet stay during the day?

Where does the pet stay at night?

Where does the pet sleep?

Does the pet....? (check all that apply)

 Like to ride in cars
 Let you take toys away
 Urinate when scared
 Come when called
 Growl at strangers

Please provide any additional information you feel is necessary regarding your answers to the last question:

Is the pet....? (check all that apply)

 Afraid of storms
 Used to children
 Good with children
 Good with cats
 Good with dogs
 Used to being groomed
 Crate trained
 House trained
 Obedience trained

Please provide any additional information you feel is necessary regarding your answers to the last question:

What commands does he/she know?

Has the pet ever growled at or bitten anyone?

 Yes  No

If Yes, please explain:

What does the pet like and dislike?

What are the pet's best qualities?

What are the dog's worst qualities?

Please provide any other information that might
be helpful for the pet's new family:

Why are you giving up the pet?

This Agreement may be executed in one or more counterparts, each of which will be deemed to be an original copy of this Agreement and all of which, when taken together, will be deemed to constitute one and the same Agreement. The exchange of copies of this Agreement and of signature pages by facsimile or other electronic transmission shall constitute effective execution and delivery of this Agreement and may be used in lieu of the original Agreement for all purposes. Signatures of the parties transmitted by facsimile or other electronic transmission shall be deemed to be their original signatures for all purposes.

(updated: 10/23/09)