Name *

First Name

Last Name

Phone *

(###)

###

####

Best time to call *

Check all that apply

Morning

Afternoon

Evening

Weekend

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of residence *

House

Apartment

Condo/townhouse

Mobile home

Do you *

Own

Rent

Is everyone in agreement with adopting? *

Yes

No

Is anyone in your home allergic to animals? *

Yes

No

Is your home fenced? *

Yes

No

Type of fencing? *

wood

chain link

vinyl

other

none

How tall is the fence? *

4 feet

6 feet

8 feet

none

Do you have cats? *

Yes

No

If yes, do your cats stay

indoors

outdoors

both

Do you have *

chickens

livestock

any other animals

none

Are all your pets spayed or neutered? *

Yes

No

Have you ever had to give up a pet? *

Yes

No

How active is your family? *

very active

somewhat active

not very active

couch potatoes

Vet's Phone Number *

(###)

###

####

Are you able to afford unexpected medical bills? *

Yes

No

Do you have a preference in gender? *

female

male

either

Are you willing to adopt a dog with minor medical issues? *

Yes

No

Maybe

Are you willing to adopt a dog with behavioral issues? *

Yes

No

Maybe

Will you allow a home visit prior to adoption? *

Yes

No

Reference #1 *

First Name

Last Name

Reference #1 Phone *

(###)

###

####

Reference #2 *

First Name

Last Name

Reference #2 Phone *

(###)

###

####

Terms *

By submitting this form, I hereby certify that all information provided by me is true and complete. I understand that any misrepresentation of information may result in any adopted animal(s) being confiscated.

I agree