Name
*
First Name
Last Name
Phone
*
(###)
###
####
Date
*
MM
DD
YYYY
Which dog would you like to adopt?
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How many years have you lived at this address?
*
What type of housing best describes your housing?
*
Do you rent or own?
*
Landlord's phone number
*
(###)
###
####
Email
*
Date of birth
*
MM
DD
YYYY
Occupation
*
Drivers license state and number
*
Please list all members living at your home. This includes all children and adults.
*
For each resident, please list :
Name, date of birth, and (if they are over 21 years of age) their drivers license number.
Please list all animals you have had in the last 10 years.
*
For each animal, please list :
Name, breed, sex, spayed/neutuered (if not, why?), current on vaccinations, do you still own this animal (if not, why?).
Who is your veterinarian?
*
Veterinarian's phone number
*
(###)
###
####
Veterinarian address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Are you willing to crate train the dog?
*
Is your yard completely fenced? If so, what is it's height? Is it a privacy fence or a chain link fence?
*
What percentage of the time will the dog spend inside?
*
What percentage of the time will the dog spend outside?
*
When they are outdoors, how will they be kept?
*
In general, how many hours will they be left alone during the day?
*
Where will this be pet be kept when you are away from home?
*
Who will be financially responsible for adequate medical care for this pet?
*
Have you ever surrendered a pet or had a pet euthanized?
*
If you responded yes to the above question, please explain.
*
Name
*
Relation
*
Phone number
*
(###)
###
####
Name
*
Relation
*
Phone number
*
(###)
###
####
