How long at this address:_______________________________________
Best time to call:______________________________________________
Family & Housing
How many adults are there in your family?________________________
How many children (ages)?
What type of home do you live in (single family, town home, apartment, farm, etc.)?
Please describe your household: __ Active __ Noisy __ Quiet __ Average
If you rent, please provide landlord’s name and number:___________________
(by providing this information you are allowing us to contact your landlord)
Does anyone in the family have a known allergy to dogs?__________________
Is everyone in agreement with the decision to adopt a dog?________________
Do you have time to provide adequate love and attention?_________________
What other pets do you have (specify type and number)?
Are these pets up to date on vaccines?
Are these pets spayed/neutered? If not..why?
Have you every surrendered a pet? If so, why?
Have you ever had a pet euthanized? If so, why?
Have you ever lost a pet to an accident?
About the Dog You Wish to Adopt
Where will the dog spend the day? (describe)
Where will the dog spend the night? (describe)
Number of hours (average) dog will spend alone?__________________________
Who will have primary responsibility for this dog’s daily care?________________
Who will have financial responsibility for this dog?__________________________
What will happen to your dog if you go on a vacation or in an emergency?
Do you agree to provide regular health care by a Licensed Veterinarian?
__ Yes __ No
Do you agree to provide grooming, as needed, by a professional groomer?
__ Yes __ No
Do you agree to consult with a professional dog trainer should the need arise?
__ Yes __ No
Do you agree to keep the dog as an indoor dog?
When the dog goes out, how do you plan to supervise it? Fenced yard?
Do you agree to contact us if you can no longer keep this dog?
How did you find us?____________________________________________________
Would you be interested in fostering? __Yes __No __Tell me more
(by providing this information you are allowing us to contact your reference)
Please list someone who is familiar with both you and your pets.
Relationship (relative, neighbor, friend, etc.):
(by providing us with this information you are allowing us to call your vet)
All of the information I have given is true and complete. This dog will reside in my home as a pet. I will provide it with quality dog food, plenty of fresh water, indoor shelter, affection, annual physical examination and vaccinations under the supervision of a licensed Veterinarian.