1. Name of Dog:

2. Where did you find out about this dog:

3. Your name:

4. Address:

5. City:     

6. State: Zip:

7. Home Phone:           email:

8. Occupation:

9. Spouse Occupation:

10. Employer:

11. Spouse Employer:

12. Your work phone:      Spouse's work phone:

13. Do you live in a:  house    condo    apartment    0ther

14. Military?

15. How long have you lived there?

16. Do you own    Rent   If you rent, do you have permission to have a dog?

17. May we contact your landlord if you rent?

18. Name of landlord:   Tel. #

19. Do you have a contract?

20. Do you have a fenced yard?

21. How high is it at the lowest point?

22. Type of fence:

23. Do you object to a home check?

24. Do you have a swimming pool?

25. How is it covered?

26. Do you have a doggie door?    If no, what access will the dog have

27. Your vet and hospital's name

28. Will the dog be indoors?   outdoors   Both

29. Where will the dog sleep:

30. Have you adopted a dog from a rescue before?

31. If yes to the above, which Rescue?

32. Where is the pet now?

33. How many hours a day will the pet be left alone?

34. Where will it stay when left alone?

35. Who will be the primary caretaker?

36. How many adults are in the household?   Children

37. List ages of children:

38. Please list the animals you have had in the past, or still have:

#1

Type of animal    Spayed/Neutered?   Place kept

How long owned?   Temperament

What happened to pet?

#2

Type of animal    Spayed/Neutered?   Place kept

How long owned?   Temperament

What happened to pet?

#3

Type of animal    Spayed/Neutered?   Place kept

How long owned?   Temperament

What happened to pet?

#4

Type of animal    Spayed/Neutered?   Place kept

How long owned?   Temperament

What happened to pet?

For what reason would you return a pet?

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