Animal:
Abbey Willow - 39792916Abraham - 37335130Anastasia - 12851736Angel - 46261195Baby - 48507935Bear - 49406040Bentley - 49074976Binx - 41145464Blue - 31381798Bongo - 45279471Bow - 34347446Browny - 49458958Bruce Kuma - 29290406Bruno - 45980336Channel - 37297815Charlie - 31784255Cody - 43236845Daisy (with Nymeria) - 49163844Deuce - 49240083Drucilla - 46170655Dylan (with Sasha) - 49388158Ellie - 37061168Ginger - 48593216Koda - 31852274Kylo Jace - 31983308Leah - 49422452Lola - 27652577Lucky - 48149326Mater - 34583349Mojo - 48184157Muppies - 49305196Nina - 46395549Nyla - 48252973Nymeria (with Daisy) - 49163870PO - 33950261Pickles - 49430201Rocco - 29297877Rocky - 49097086Roxy - 48388527Rumby - 43081590Sasha (with Dylan) - 49388145Savanna - 19632172Smokey - 49340222Xavier - 48766669Zoey - 49010409

First Name:

Middle Name:

Last Name:

Age:

Phone #:

Email Address:

Address:

Apt #:

City:

State:

Zip Code:

County:

First Name:

Middle Name:

Last Name:

Age:

Phone #:

Email Address:

Do you:
Own
Rent
Live with relative

Who is the homeowner/landlord?

Homeowners/Lordlords Phone #:

Could you be moving/being deployed soon?
Yes No

Please explain:

If you had to move/be deployed, what would you do with the animal?

Are you currently employed?
Yes No Retired

Where?

How many other adults and children live in the home?


Please list their name, age, and contact numbers below:

Does anyone in the home suffer allergies related to animals?
Yes No

Please explain:

By your best estimate, how much money do you anticipate to spend on a pet each year (vet care, food, toys, etc)
$

How many hours per day would the animal be left alone on a normal day?

Who will be the animals primary caregiver?

Are you familiar with the breed and behavior of this dog?
Yes No

Please explain:

Please explain your housebreaking plan:

Do you have a fully fenced yard?
Yes No

Please describe your fenced yard:

Please describe your plan for exercise/bathroom breaks:

Please describe your PREVIOUS pets (Include pet names, breeds, spayed/neutered, dates owned, etc.):

Please describe your CURRENT pets (Include pet names, breeds, spayed/neutered, when owned, etc.):

Which veterinary hospital did your previous pets attend?

Veterinary Hospital Phone #:

Which veterinary hospital do your current pets attend?

Veterinary Hospital Phone #:

What persons name would the vet records be under?

Are your current pets up-to-date on vaccines and preventative medications?
Yes No N/A

Where will the dog be kept during the day?

Where will the dog be kept at night?

What would you consider a valid reason to give up/return this animal?

Have you ever surrendered to a shelter or re-homed an animal before?
Yes No

Please explain:

Please use this box for any additional information you'd like us to know: