This questionnaire will allow us to determine whether your dog is suitable for placement by our organization. Please be as honest as possible.

Your full name:

Address:

City: State: Zip:

E-Mail Address: Home Phone Number:

Names and ages of all children living with you:

Name of your dog:

Breed of dog: Rottweiler Pit Bull Terrier American Staffordshire Terrier Other

Age of dog:

Sex: Male Female

Weight:

Where did you get the dog: Breeder Pet Store Former owner Shelter Stray

How long have you owned the dog:

Is the dog spayed/neutered: Yes No

Is the dog up to date on vaccinations: Yes No

Was your dog tested for heartworm and on preventative last summer Yes No

Is you dog currently in a healthy condition?: Yes No

If you answered no, please describe:

Is your dog:

Housebroken Crate Trained A barker A digger

Is your dog good with other dogs:

Yes No Unsure

Is your dog good with cats:

Yes No Unsure

Is your dog good with children:

Yes No Unsure

Has your dog ever bitten a human:

Yes No

If yes, please describe:

Why are you surrendering this dog:

What steps have you taken to try and keep your dog:

Are you willing to explore options to keep the dog: Yes No

Anything else we should know about your dog:


Are you able to keep and care for this dog until a new home is found:

Yes No

How did you find out about A Rotta Love Plus?


Thank you for completing this questionnaire. We will review it and make and inital determination as to whether your dog meet the criteria for our self-foster program. You also agree to a personal interview with a member of A Rotta Love, and we will need to meet the dog and review it's veterinary records prior to acceptance.

Owner Signature(s):

**If the form is incomplete, we will not review it. Thank you. **