Name (First and Last)
Email
Street Address
City and State
Phone Number
Date of Birth
Occupation
Do you live with:
Spouse/Partner
Roomate(s)
Parents
Alone
How many adults (over 21) live in household?
How many individuals under 21 live in household?
What are the ages of individuals under 21 in household?
How far would you travel to pick up dog?
Name of dog you are interested in
Are you looking for a:
Male
Female
Doesn't matter
Prefer dog to be:
Already spayed/neutered
Not spayed or neutered
Doesn't matter
How long will the dog be left alone on an average day?
Dog's living situation:
Dog will be family pet, living inside the house
Dog will live in the garage or basement
Dog will live outdoors
Guard dog
Other
If you choose other, please explain:
When home alone, dog will be:
In a crate, kennel, wire cage or pen inside the house
In an outdoor kennel
Tied up outside on a chain
Tied up outside on a cable run
Dog will be loose, inside house
Dog will be loose outside
Other
If other, please explain:
How will you exercise the dog?
Leash walks everyday
Will have cable or dog run in yard
Will be free to run in fenced-in yard
Will have supervised access to unfenced yard
Will be free to roam around (off leash, unsupervised, in unfenced yard)
Will take to dog park (where dogs are free to run and play together off leash)
Other
If other, please explain:
What type of area is your home in?
Suburbs (outer city)
Urban (inner city)
Rural (country)
Is your yard enclosed by a fence?
Yes
No
If yes, height, length and type of fence
Do you live in a:
House
Apartment/Condo/Townhome
Mobile/Modular home
Do you own your home?
Yes
No
If renting, please provide landlord's name and phone number for verification
Does your municipality/county have breed specific legislation
Yes
No
Does your homeowner's insurance policy restrict certain breeds of dogs?
Yes
No
Not sure
Don't have homeowner's insurance
Do you have other dogs?
No other dogs
One or more spayed female
One or more neutered male
One or more UNspayed female
One or more UNneutered male
Other
If other, please explain
If you've had other dogs in the past, what is their current disposition?
Still have dog
Passed away from old age/fatal disease
Gave away or sold to family or friends
Was hit by a car
Lost/Stolen
Other
If other, please explain:
What other kind of animal(s) do you have?
If you have experience with bully breeds, please explain:
Please provide the name and phone number of your veterinarian.
Additional information you would like to provide about yourself.
Please provide two (2) personal references (name, phone number and relationship to you):
