Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do you *

Rent

Own

Do you live in *

House

Apartment

Condo

Mobile Home

Other

Is anyone in the home allergic to dogs or cats? *

Yes

No

Does everyone in the home want to get a pet? *

Yes

No

Where will the pet primarily live? *

Inside

Outside

For Dogs: which of the following do you plan to use?

Tie Out

Dog House

Crate

Fenced Yard

Yard (no fence)

Outside Pen

Leash

Invisible Fence

Basement/Garage

How many hours will the pet be alone each day? *

1-4

5-8

9-12

12+

Have you ever relinquished an animal to an animal shelter or individual? *

Yes

No

Is there a chance you will be moving within the next year? *

Yes

No

Have you owned a pet within the last 5 years that is not listed above? *

Yes

No

Have you adopted from a shelter before? *

Yes

No

Are your pets spayed/neutered? *

Yes

No

N/A

Are the dogs on heartworm prevention? *

Yes

No

N/A

Do you have a veterinarian? *

Yes

No

Date

MM

DD

YYYY