Interested in:




State:           Postal Code:  

Home Telephone:

Work Telephone:


Do you presently care for/own pets?:yes/no

If yes, please list name, species and breed:

If dogs are present, are each spayed/neutered? yes/no

If no why?

Are there dogs no longer in your household? yes/no

What happened to those animals? 

Please provide name and telephone number of your current vet:

If you do not have a vet list name and phone number of vet you will be using:

How many children living in household?:
Age of Children?

Do you own or rent?:

Do you reside in a house, apartment, other?:

Of renting, do you have landlord permission?: yes/no

Landlord phone number:

If you have a fence, what kind:

How many hours if any will your dog be left unattended?:

Where will your dog be kept while you are away?:

Do you have enough crates to house dogs in your household?: yes/no

Where will the dog be kept while you are on vacation?:

Why are you interested in adopting a dog?:

Will you allow a home visit prior to to adoption?: yes/no

Will you enroll the dog in obedience classes if necessary?: yes/no

Will your dog always be on a lead when inopen spaces?: yes/no

Please provide the name and telephone number of 2 personal references:

NOTE: Please contact your vet and authorize them to release medical information.

What brand of food do you feed your pets?
Would you be willing to feed a high quality grain free food? yes/no
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