Name: 

Spouse: 

Address:

City:   State:
ZIP:

E-Mail: 

Home Phone: Accept collect calls? Yes No

Your employer:
Phone:

Spouse employer:
Phone:

Age Are you expecting a child or planning a family? Yes   No

Does your or your spouse's job require frequent out of town travel?
Yes No

Are you or your spouse subject to relocation?Yes No

Are you a student?Yes No;   If 'yes' anticipated date of graduation:

Are you in the military?Yes No;   If 'yes' anticipated date of discharge:

How many children are living at home?

Names and ages of all children included above:

Besides your immediate family, are there others residing in your home?
Yes No

Names of other residents:

Relationship of other residents:

Is anyone in your home allergic to animals?Yes No;   Does anyone have asthma? Yes No

Do you own or rent? own rent

If you rent, please provide name and phone number of your landlord:

Please describe your type of dwelling: Please select Apartment Duplex/Triplex Townhouse/Condominium Mobile Home House Farm/Ranch

How long have you lived at your current address?

If less than two years, please provide your previous address:

Please descibe your neighborhood: Please select City Suburb Country/Rural

Does your home have a yard?Yes No

Does fencing completely enclose the yard for the dog?Yes No

If not, explain how and where you will allow the dog to exercise and relieve itself?

If your yard is fenced please describe what kind:

How tall? 

Is the gate currently locked with a padlock? Yes No

Can strangers gain access to your yard from the street? Yes No

Some insurance companies may cancel your homeowner's insurance if you own certain breeds of dogs. It is your responsibility to check with your agent and ensure that adopting a dog will not adversely affect your policy.

Do you have other pets at this time? Yes No

If 'yes' are they spayed or neutered yet? Yes No

If 'yes' are they currently on heartworm preventative? Yes No

If 'yes' are they indoor or outdoor indoor outdoor

Please describe your pets in detail including gender:

What petfood are you feeding your pet(s):

If you have owned pets in the past and do not now, what happened to them?

Have you ever owned a dog before?YesNo

Are you looking for primarily an indoor dog or primarily an outdoor dog: inside outside

What role would you like your new dog to play in your life? {please check all that apply}:

companion/family pet   obedience   protection   therapy   hunting  
other (please specify) 

Please describe where the dog will stay when you are at home:

Please describe where the dog will stay when you are away:

Please describe where the dog will sleep at night:

How many hours per day will the dog be alone?

Do you have a crate? Yes No

Do you plan to use a crate? Why or why not?

If 'yes', how many hours per day will the dog be crated?

Do you currently have a dogdoor? Yes No

If 'no' would you consider putting one in? Yes No

What kinds of solutions would you be willing to try if housebreaking accidents occurred? {please check all that apply}:

crate  dog door   leave outside   none, I would need to return the dog  

other (specify) 

Have you ever trained a dog before?Yes No

If 'yes' please describe the training methods you have used in the past:

Are you familiar with the signs of gastric torsion [bloat]?Yes No

Please provide us with your current veterinarian information {required}:
Name
Address
City
State Zip Telephone

If you have been going to your current veterinarian for less than five years, then please provide us with your previous veterinarian information:
Name
Address
City
State Zip Telephone

Reference #1:
Name
Day Phone   Eve Phone

Reference #2:
Name
Day Phone   Eve Phone

Reference #3:
Name
Day Phone   Eve Phone

Do you have a gender preference?   age preference?

Do you understand that often times the complete history of a rescued dog may not be known and you may encounter some initial adjustment problems? Yes No

Will you be willing to work with us on solving those problems if they occurred?
yes  no, I would need to return the dog  

If 'yes' please describe a reasonable timeframe within which you feel the dog should have acclimated:

Is there a dog on our web page that you are especially interested in?

If you were referred by anyone, please tell us so we may thank them:

Please give us any other information that may help us make the best match between you and your new dog:

Please doublecheck that you have filled in all the fields - indicating 'n/a' if a question does not apply to you - incomplete applications cannot be processed and will be deleted..

By clicking the 'submit' button I certify that the above information is true. I further certify that I am financially and physically able to care for this animal. I understand that proper food and veterinarian care can be costly and I am able to meet these obligations. I understand that home checks may be made on a random basis prior to or following adoption. If any information contained in this application is found to be false, I understand the dog will be removed from my premises without a refund of monies paid.

Please note that this application does not guarantee placement.