Puppy/Dogs Name* :  

Applicant's Full Name Name*:   

Address
Street*:   City*:    State*:    Zip*:  

Phone Home: With Area Code *         

Phone Work: With Area Code    

Email Address*:  

Why do you want to adopt a pet?*
 

Who will be the primary caretaker of this pet:*
 

Where will the pet stay when no one is home.  Be Specific?

Where will the pet stay when the family is on vacation?


Is there anyone in the home who may be adversely affected by care of dogs/cats
(allergies, etc.)?

Do you live in a:   *                      Do You: *
  House Apartment Mobil Home                                     Own Rent

If rent: Do you have the landlord’s permission to have a dog?
Yes No

Landlord Name/Phone #

Do you have a fenced yard*?          Yes No

Yard Size

Type and height of fence?

Or do you live in the country on acreage?  Yes No  

Distance to nearest busy roadway?

Where will the animal be kept during the day? At night?

Will this be your first pet *? Yes No  

List any other pets you have, if they are on heartworm preventative and if they are spayed or neutered:

Do your pets get along with other animals?

Have you had other pets in the last 5 years and what became of  them? 

Are your pets up to date on vaccinations?
  Yes No

May we contact your veterinarian?
  Yes No                                                     

Please provide name, address and phone # of most recent veterinarian:

Are you prepared for the expenses of monthly Heartguard, Frontline and quality food and yearly boosters, emergency medical care and routine care for possibly  10-15years? *
  Yes No

Adults in the home *:   Children in the Home Children’s ages

Do all members of household want to adopt this pet? *
  Yes No

How long have you lived at your present location?*          

Do you anticipate moving in the near future? *
  Yes No

Are you willing to make a lifetime commitment to this pet?*
  Yes No

Additional comments: