Surrender Application How many pugs are you surrendering?* One Multiple (Please complete a form for each Pug) Pug's Name*Is this a prior PRoNE pug?* Yes No Age*Neutered or spayed?* Yes No Gender*Color*Where did you get this pug?* Breeder Friend Craigslist or online Pet store Shelter or Rescue Your Name*Email* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Are you the legal owner of the Pug?* Yes No Are you the first owner? If not, list previous owner.*Do you have a contract with the breeder for return of the dog?* Yes No How long have you had this pug?*Is this a purebred Pug? Please note, we will consider pug mixes on a case by case basis.* Yes No Tell us about your pug. (check all that apply) Fine with other dogs Fine with cats Fine with young children Best with older children No kids for this pug, please! Crate trained Housebroken Working on house breaking, needs some help Friendly and easy going Walks well on the leash Needs structure & routine High energy Other If you chose other above, please tell us why here.Reasons for surrendering (check all that apply) New baby Allergies (pug) Not enough time Moving, cannot take dog Found as stray Behavior problems Health Issues (Owner) Health issues (Pug) Cannot afford care New home Other If you chose other above, please tell us why here.Please select health issues (check all that apply) Eye issues Ear issues Breathing issues Heartworm positive Lyme positive Diabetic Seizures/epilepsy Arthritis/joint/mobility Paralysis Mange or skin infection Blind Deaf Allergy No health issues Please select any behavior issues (check all that apply) Has shown aggression towards dogs Has shown aggression towards cats/small animals Has shown aggression towards children Has shown aggression towards adults Destructive / separation anxiety Has shown resource guarding (guards food/toys/people Hyperactive Trouble house training / marker No behavior issues Please explain behavior problems (be specific).*Is your pug on any medication?* Yes No Please list medications.Current Vet's Name*Vet's Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Vet's Phone*Date of Last Shots* MM slash DD slash YYYY Has your pug been vaccinated against rabies within last 3 years?* Yes No Has your pug had distemper vaccine within last 3 years?* Yes No Has pug been tested for heartworm and lyme within the last year?* Yes No Heartworm & Lyme results* HW negative, taking monthly preventative HW negative, no monthly preventative HW positive, treatment needed Lyme positive, no treatment Lyme positive, being treated No testing for heartworm/lyme How did you hear about PRoNE? PRoNE Website Search Engine Facebook Friend Vet Surrender time frame? Your honest answers, vetting needs and available foster homes determine how quicky we can take in any pug/pugs.* My situation is an emergency. 1 to 2 weeks 2 to 3 weeks 3 to 4 weeks 4+ weeks Upload a picture of your PugMax. file size: 100 MB.Please tell us anything else that you think we should know about this Pug.
