Your email address:

Your name:

Spouse/Roommate(s) name:

Second Chance dog you are interested in:

(OR) Breed of dog you are interested In:

Your address:

City:

State:

Zip:

Home phone #:

Work phone #:

Spouse's work phone #:

Your work hours and days:

Your spouse's work hours and days:

Rent or own home:

Landlord's name:

Landlord's address:

Landlord's phone #:

Do you have children?:

Children's ages:

Do you have cats?:

Are they altered?:

Do you have a dog or dogs now? (yes or no):

Breed (s)?:

Sex(s)?:

Age (s)?:

Are they neutered?:

If you don't have a dog now, when was your last dog and what happened to that dog?:


Have you ever adopted or owned a dog that did not work out and you relinquished? (yes or no):

If YES,
What was the reason for giving up the dog, how did you handle the Situation, and then where did the dog finally go?:


Name of your veterinarian?:

Phone # of your veterinarian?

Is your yard contained?:

Describe your yard:


Describe your fence:


Would or do you allow your dog inside your home?
Explain please:


Where would or does your dog sleep?:

Would you be willing to take obedience classes with your new dog? If no, please explain:


How will you discipline your dog?:


What will you do with your dog when you travel?:


How physically active are you?: Select Here Couch Potato! Occasional Walk Pretty Active... Athlete

Do you have any allergies? If so, to what?:

Please list three personal references whom you have known for at least five years (include addresses and phone numbers).

Personal reference #1


Personal reference # 2:


Personal reference #3:




Any other comments for us?: