Name of Owner:
Address of Owner: (street)
(city)
(state)
(zip)
Telephone: Home:
Work:
Best time to be reached by phone:
Email address:
Name of Dog:
Sex:
Color:
Is this a purebred Basset Hound?
Yes
No
If no, what kind of mix is it?
Neutered/Spayed?
Age/Date
of Birth
Innoculations/Dates:
Heartworm Test?
On Preventative?
Next due
Dog obtained from (name, address, phone number)
If surrendering, explain why:
By what date must you relinquish the dog:
Known personality/temperament traits:
Feeding Schedule/type & brand of food:
Housebroken?
Schedule:
Other known information:
Has the dog ever bitten a person?
Another animal?
If
yes, explain:
Have you contacted any other Rescue Organizations about your dog? Yes
No
If Yes, which one(s)?
I certify that the above information is true and accurate to the
best of my knowledge.
Signature:
Date:
Please print this form and return it (with an original signature - no copies or faxes) with photo(s) of the dog, to: BROOD Inc., 3445 Seminole Trail, Box 248, Charlottesville, VA 22911. For more information, email giveups08@brood-va.org or call 866-710-9476 (toll free) and leave a message.