| e-mail: required |
| First :required |
Last :required |
| Telephone :
'required' |
Cell phone :
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| Address:
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Street Address :
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| City:
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State:
Zip: |
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| Occupation:
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| Spouse/Significant Other |
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First:
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Last :
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| Number of persons in household:
Adults:
children:
ages of children:
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List at least 3 Personal Reference (Name and Telephone Number) |
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| |
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| Do you have grandchildren?
No
Yes |
If so, what are their ages:
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| Does anyone in your home have allergies to dogs?
No
Yes |
Home Information
|
| Which best describes your home: |
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If Other, please describe: |
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| Is your home rented?
No
Yes |
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If rented please list your landlord and contact information (phone / address) |
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| Do you have a fenced yard?
No
Yes |
If Yes, what type of fencing do you have?
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Height of fencing? |
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Length of fencing? |
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Width of fencing? |
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| Does the gate latch securely?
No
Yes |
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| Will you be moving soon?
No
Yes |
If moving, where?
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| If you move, what will you do with the dog?
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Pet Information |
Please list all veterinarians used and all pets owned in the last 5 years. |
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| Primary Veterinarian's Name: |
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| Veterinarian Hospital Name: |
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| Telephone : |
Address: |
| City:
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State:
Zip:
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| Name and telephone number for all other veterinarians used in the last 5 years
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Total number of pets owned in the last 5 years: |
required |
| |
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| Do these pets get along with each other?
No
Yes |
Where did you get your pets?
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Pet 1
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| Breed : |
Sex:
Male
Female |
| Name :
|
Age :
year(s) |
| How long has (or did) this pet live with you? : |
years. |
| Where is the pet now :
|
Spayed or Neutered?
No
Yes |
| Up to date on all shots? :
No
Yes |
On monthly heartworm preventive?
No
Yes |
| |
|
Pet 2
|
| Breed :
|
Sex:
Male
Female |
| Name :
|
Age :
year(s) |
| How long has (or did) this pet live with you? : |
years. |
| Where is the pet now :
|
Spayed or Neutered?
No
Yes |
| Up to date on all shots? :
No
Yes |
On monthly heartworm preventive?
No
Yes |
| |
|
Pet 3
|
| Breed :
|
Sex:
Male
Female |
| Name :
|
Age :
year(s) |
| How long has (or did) this pet live with you? : |
years. |
| Where is the pet now :
|
Spayed or Neutered?
No
Yes |
| Up to date on all shots? :
No
Yes |
On monthly heartworm preventive?
No
Yes |
| |
|
Pet 4
|
| Breed :
|
Sex:
Male
Female |
| Name :
|
Age :
year(s) |
| How long has (or did) this pet live with you? : |
years. |
| Where is the pet now :
|
Spayed or Neutered?
No
Yes |
| Up to date on all shots? :
No
Yes |
On monthly heartworm preventive?
No
Yes |
| |
|
Pet 5
|
| Breed :
|
Sex:
Male
Female |
| Name :
|
Age :
year(s) |
| How long has (or did) this pet live with you? : |
years. |
| Where is the pet now :
|
Spayed or Neutered?
No
Yes |
| Up to date on all shots? :
No
Yes |
On monthly heartworm preventive?
No
Yes |
| |
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If more than 5 please list the same information for the others:
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How and where do you exercise your pets?
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Who will supervise these activities?
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| Will the dog have the run of the house?
No
Yes |
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| How many hours would the dog be alone on a typical day?
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| How will you discipline the dog if (s)he misbehaves?
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| Where will you keep your pet |
|
| during the day? |
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At night? |
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| Why are you looking for a pet? (check all that apply) |
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