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Name of dog you're interested in
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Telephone: Home
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Telephone: Cell
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Telephone: Work
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Your name is
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Your city: state: zip code is
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How long have you lived here?
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Is this a: House, Condo, Townhouse, Duplex, Apartment, Mobile Home
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Do you: Own this dwelling or rent it?
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Do you: Live with roommate? Live with parents?
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Name of apartment complex and landlord's phone #
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(Internal use only) - Proof of pet deposit verified by )
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Are you 21 years old?
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Are you: Employed / Unemployed / Retired / Work at Home
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Employed where? How long?
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If you are a stay-at-home mom, please give name of husband's employer and phone #
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Why do you want me?
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Does your spouse want me? Yes / No / Not sure / N/A
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Does anyone in your household DISLIKE dogs? Yes No Not sure
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Who will be responsible for my care?
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How many adults live in your home?
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How many children are in your home?
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Does any member of your family have allergies? If yes, to what?
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Does any member of your family have respiratory problems?
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What will you do with me if any member of your family develops allergies or respiratory problems?
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Does anyone in your household smoke? If yes, how much?
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As an ADULT, how many animals have you had? Where are they now?
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Which of your other pets live indoors? Which live outdoors?
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Are all your other pets spayed or neutered?
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Are all your other pets up to date on vaccinations? May we verifty this with your veterinarian?
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Who will be my veterinarian? ( Please give name, clinic name, and phone number )
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Will I have a fenced yard to play in?
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What behaviors will you NOT tolerate?
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Are you willing to, and do you have the time to dedicate to correcting these behaviors?
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Can you afford to take me to obedience school?
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How long will I be alone during the day?
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Where will I stay during that time?
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Have you ever given away an animal? If yes, please explain.
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Please list which of the following reasons you would give an animal away: allergies, moving, parents moving in with you, having a baby, divorce, loss of job, going back to work, no time for the dog, retiring, agression, barking, chewing, digging, not housebroken,
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In your own words, what does "Lifetime Committment" mean to you?
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Your stree address is (no P.O.Boxes):
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