First Name (required)

Last Name (required)

Email address (required)

Address 1

Address 2

City

State
Alabama Alaska Arizona Arkansas California Colorado Conneticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinios Iowa Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Neveda New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Caronlina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Zip/Postal Code

Home Phone

Work Phone

Cell Phone

Household is shared with (check all that apply)

• 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 breeds, weights, and ages.

Your occupation

Housemate’s occupation

Type of dwelling
single family home condominium apartment guest house duplex triplex farm or ranch

I rent my home

I own my home

Do you have a dog door?
Yes     No

Outside areas available to dog: (check all that apply)

• fenced yard
• unfenced yard
• kennel/run
• patio
• garage
• balcony
• dog house
• no outside areas

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: 0 1 2 3 4

Height of gates

Is there any type of lock on gate(s)?
Yes     No

Excluding members of your own household, who has access to your fenced yard or patio when you are not home? (check all that apply)

• nobody
• gardener
• pool maintenance
• meter reader
• mail carrier
• delivery person
• housekeeper
• other

Do you currently have a veterinarian?
Yes     No

Name of your veterinarian

Your veterinarian’s telephone number

What kind of dog food will you feed your dog?

Brand of kibble

Brand of canned food

Other food

Are you open to feeding suggestions?
Yes     No

How many hours will the dog be alone every day?
never alone 1 hour(s) 2 hour(s) 3 hour(s) 4 hour(s) 5 hour(s) 6 hour(s) 7 hour(s) 8 hour(s) 9 hour(s) 10 hour(s) 11 hour(s) more than 12

During what hours will your dog be outside?

Where will the dog sleep at night? (please be specific.)

Primary reasons for adopting a dog: (check any that apply)

• companion for family
• companion for myself
• companion for spouse
• companion for kids
• companion for other pet
• want a watch dog
• want a hunting dog
• give as gift
• other

Are you looking for a house dog or a yard dog?
House dog     Yard dog

Will you walk your dog(s) off leash?
Yes     No

Would you object to an inspection of your premises by one of our volunteers?
Yes     No

Have you ever trained a dog in obedience class?
Yes     No

How will you discipline your dog if it misbehaves? (Check any that apply.)

• use newspaper to spank
• scruff neck
• spank rear end with hand
• swat nose
• stern voice
• other

If you checked “other” above, please give details.

After 6 months of ownership, what would be your main reasons for giving up your dog? (select any that apply)

• excessive barking
• poor watchdog
• occasional “accidents” in the house
• biting someone
• growling at house guests
• digging in the yard
• destructive chewing
• biting me
• moving to a new location
• none of the above

In the field below, 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).

BREED - LENGTH OF OWNERSHIP - HOW OWNERSHIP ENDED:

If you have additional comments about any of the answers that you have given, please put them below.