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Personal Name Address City State Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Mississippi Missouri Minnesota Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennesee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip Email Day Phone Evening Phone Birth Date Occupation What dog are you interested in? References Name Phone Relationship Name Phone Relationship Employer Address Phone Spouse Employer Address Phone Vet Name Phone Records Under Name of Household Home Own     Rent Are You Moving Soon? Y     N If Yes, Explain Landlord Name Phone List below all people who currently live at this residence. Name: Age: Relation: Name: Age: Relation: Name: Age: Relation: Does anyone in your house have any allergies to dogs? Y     N List below any cats, dogs, etc. who currently live in your household: Name: Breed: Age: Sex: Spayed/Neutered: How long owned: Kept where? History Owned a Dog Before? Y     N Owned a Large Breed? Y     N Owned a Large Bully Breed? Y     N If Yes, Explain What Happened To It If your last dog died, please state the dog's name and date deceased: Have you ever taken one of your pets to a shelter? Y     N If Yes, please describe the circumstances Do you have any previous experience in dealing with a dominant or aggressive dog? Y     N Care of the Dog Do you have a fenced area on your property? Y     N Is the area completely fenced? Y     N If so, the fence is this high... ...and the inside area is this sq ft. What type of fencing do you have? If you have no fence, how do you plan to have your new dog relieve/exercise itself? How active is your lifestyle aside from work? Please explain: Do all adults work full time? Y     N How many hours each day will you spend time with your new dog? Where will your new dog be kept when it is alone? Where will your new dog sleep? What sort of training do you plan on providing the dog? Are you agreeable to having a homecheck done prior to adoption? Y     N How far are you willing to drive to meet a potential adoptee? We request a donation and depending on the expenses incurred in thedog's/puppy's rescue and veterinary care this could range from $200.00 to $300.00 All animals are spayed/neutered prior to placement. Is this acceptable? Please realize that dogs need vet care throughout their lives, including yearly boosters, heartworm and flea/tick preventative meds, etc. If you cannot afford a donation, can you afford the appropriate vet care? please consider this before adopting. Are these terms acceptable to you?If so, please indicate by checking below: I confirm all information, and agree to the above.