Name::

Home Phone::

Work Phone::

Email::

Occupation::

Home Address::

Address 2::

City::

State::

Zip Code::

Years at Address::

Months at Address::

Do you Rent or Own?:

If you rent, do you have landlord's permission to own a pet?:

Landlord Name::

Landlord Phone::

Do you have a fenced backyard?:

If yes, is it attached to the house?:

Do you have a pool?:

May we visit your home?:

When?:

Do you have children in your household?:

List ages of all children::

Are you planning on having children?:

Are there any other people in your household?:

Does anyone in your household have any allergies?:

Who will be the primary caretaker of the dog?:

Why do you want a dog?:

Which dog are you interested in?:

Do you have a second choice?:

If no specific dog, do you have a specific breed preference?:

Do you have a gender preference?:

Would you accept a mixed breed?:

Would you accept a dog with special needs?:

Are you planning to crate train?:

How are you planning to exercise the dog?:

Please provide us with some information about your lifestyle::

Where will the dog be kept during the day?:

Where will the dog be kept during the night?:

Where would the dog stay if you go on vacation?:

If you have to move, what would happen to the dog?:

Are there any behaviors, or reasons, for which you would give up the dog?:

Do you have other pets?:

Number of dogs: (Breed/Name):

Number of Cats: (Names):

Number of other pets: (List please):

Are they all current on vaccines, heartworm, and flea prevention?:

If you have pets, please give us the name of their vet::

Vet Phone::

Do we have permission to contact the vet (if applicable)?:

Do we have permission to contact your landlord (if applicable)?: