Owner Relinquishment Form

Owner's Name:
Address:
City:
State:
Zip:
Phone number (with area code):
Email Address:
Springer's Name:

General Information on the Springer
Age:	Sex:	Male Female	Vacinations Current:	Yes No
Weight:	Spayed/Neutered:	Yes No	Housebroken:	Yes No
Color:	Crate Trained:	Yes No	Separation Anxiety:	Yes No

Reason for Relinquishment?

Are you the original owner? Yes No
If not, what is the dog's history?

I found this dog as a stray. If so, how long ago?

Vet's Name:
Vet's Address:
City, State, Zip:
Vet's Phone number:

Does he/she have any medical conditions? Yes No
If so, please give details:

Any history of biting? Yes No
If so, please give details:

Is he/she good with children? Yes No Not sure
If so, what ages? Any other comments?

Is he/she good with other dogs? Yes No Not sure

Is he/she good with cats? Yes No Not sure

Does he/she ride well in the car? Yes No Not sure

Is he/she good at the groomer? Yes No Not sure

Where does the dog stay during the day?

Where does the dog sleep?

Any other comments:

Contact MAESSR
If you have limited email access, or if you know of a Springer in need, you can contact MAESSR by telephone at (301) 362-0423 or you can always email us.

MAESSR Mailing List
For regular information on what MAESSR is doing or just questions about MAESSR, join our mailing list by sending an email to our mailing list.