posted 01-27-2004 02:14 PM         

City:

Zip:

State:

Home Phone:

Work Phone:
E-mail:

License number:

How old are you?

Occupation:

Do you live with spouse/partner?
Roomate(s)
parents
Alone

How many adults (21 & older) in your household?
How many individuals under 21 in your household?
What are the ages of the individuals under 21?

How far could you drive to pick up a dog?

LIABILITY & RESPONSIBILITY
By Checking YES, you agree that the dog is to be kept as a household pet. It shall not be sold for medical or experimental purpose, and it shall not be used for breeding YES_____ NO_____
Dog(s) you are interested in adopting? Choice#
Are you looking for a: Male Female Either?
Do you prefer a puppy adult either
color Size
Do you prefer additional requirements about the dog you would like to add?
Dogs living Situation: Check all that apply:
Dog will be a house pet living inside with family
Dog will be in a basement or garage
dog will live outdoors
dog house will be provided
guard dog for business or residence
other: Please specify:
How many hours a day will the dog be alone?
When home alone dog will be (check all that apply)
in a crate
Wire cage
inside dog pen
In a kennel: Outdoor Indoor Both
Tied up outside: Cable run On a chain
Dog will be loose: Indoor Outdoor Other (please specify)

How will you exercise the dog
Leash walks daily
Will have cable or dog run in the yard
will be free to run in fenced yard
will have supervised access to unfenced yard
Will bring to dog park (Public area where dogs can run & play together off-leash)
Other:
Is the home in an urban suburban rural setting?
Yard size: Small Medium Large No yard
Is the yard enclosed by a fence:
If so, height, length, and type of fence
Do you live in a house apartment trailer
Do you own the property:
If you are renting, provide the name, address, and phone number of your landlord for verification.

Other Pets and Experience:
Do you have other dogs?
How many?
What breed?
Spay Neutered
Ages?
If you have had other dogs in the past, let us know of their current disposition:
Still have the dog(s)
Died of old age
Fatal disease (what type)
Gave or sold to friends, relatives, or acquaintances
Was hit by a car
Was stolen
Disappeared/lost
Specify what happened:
What other kind of animals do you own?

References: Please supply the name and phone number of your current veterinarian as well as your past veterinarians . ( With their title identification.) If you don't have a vet, please provide the name of your employer, clergyman, or anyone not related to you who can attest to your character.
***** Vet References are PREFERRED*******
Additional information you would like to provide about yourself and/or the dog you would like to adopt:

Are you willing to be responsible for the animal you are adopting for its entire life approximately 12-20 years?

Signature:
Date: