Date:
Dog You Are Interested In:
Basic Information
First, last name:
E-mail address:
Physical address:
Home phone:
Cell phone:
Household information
Household is shared with:
Spouse
Significant other
Children
Other family member(s)
Roommate(s)
Live alone
Number children and their respective age(s).
Do you have other pets?
If so, please list name, breed, weight, age and if they are spayed/neutered.
Occupation
Your occupation
Housemate’s occupation
Your Home
Describe the type of home you live in:
Do you own or rent your home?
If you rent your home do you have permission from your landlord to have pets living on/in the premises?
*Please give us your landlord’s name, address and phone number.
Do you have a dog door?
Your Yard
What type of outdoor area is available for your dog?
Is your yard fenced?
Answer the following 6 questions if you have a fenced yard or patio.
Height of fence at highest point
Height of fence at lowest point
Number of gates
Height of gates
Is there any type of lock on gate(s)?
Dog Care
Do you currently have a veterinarian?
Name of your veterinarian and location:
Your veterinarian’s telephone number
Do you give us permission to contact your vet for a reference?
If no, please explain.
What brand of dog food will you feed your dog?
Are you open to feeding suggestions?
How many hours will the dog be alone every day?
During what hours will your dog be outside?
Where will the dog sleep at night? (please be specific.)
Are you prepared to purchase a crate for your new pet if necessary?
Are you prepared to pay for and attend obedience classes if necessary?
Prospective owner - additional information
Primary reasons for adopting a dog:
Is this dog a gift?
Are you looking for a house dog or a yard dog?
Will you walk your dog(s) off leash?
Do you consent to an inspection of your premises by one of our volunteers?
Have you ever trained a dog in obedience class?
How will you discipline your dog if it misbehaves?
After 6 months of ownership, what would be your main reasons for giving up your dog?
__excessive barking
__digging in the yard
__poor watchdog
__destructive chewing
__housetraining
__biting someone
__growling at house guests
__biting me
__moving to a new location
__none of the above
Please list all of the dogs that you have previously owned and cared for—going back to when you were 18 years of age. For each dog, please provide the breed, length of ownership, and explain if the pet was lost, given away, stolen, sold, surrendered to an animal shelter or if it died (state the cause of death).
If you have additional comments about any of the answers that you have given, please put them below.
