First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Cell Phone*

What is the name of the Dog?*

Age and Gender:*

Microchip Company and Microchip Number:

Acknowledgment of Surrender and Microchip Transfer I/we confirm that I/we have permanently surrendered the dog listed above to Great Plains Pointer Rescue, Inc. (GPPR). I/we give up all ownership rights and authorize GPPR to update or transfer any microchip registration connected to this dog. By typing or signing my/our name(s) below, I/we agree that this electronic signature has the same legal effect as a handwritten signature. (Please e-sign by entering your name and date.)*