Personal Information
Name
__________________________________________________
Spouse
__________________________________________________
Address
__________________________________________________
City
__________________________________________________
State
_______________________ Zip _______________
__________________________________________
Home phone
__________________________________________
Does you or your spouse's job require frequent out-of-town travel? ___________________
Are you or your spouse subject to relocation? _________________
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Are you in the military? |
________________________ |
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If "yes" enter anticipated discharge date _____________ |
Family Information
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How many children are living at home? |
_____________________ |
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Ages of all children listed above: |
___________________________________________ |
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Besides your immediate family members, are
there others residing in your home? |
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If "Yes" names and relationships of all others residing at your home |
______________________________________ ______________________________________ |
Home Information
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How long have you lived at your current address? |
__________________________ |
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Please describe your neighborhood: _______________________________ ________________________________________________________ |
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Please describe your type of dwelling: _________________________________________________________________ |
Do you own or rent? ________________
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If you rent, please provide the name and phone number of your landlord: |
_________________________________________ _________________________________________ _________________________________________
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Does your home have a yard? _______________
If yes, please describe restraint system: __________________
If your yard is fenced, please describe what kind:
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Other Pet Information Do you have other pets at this time? _____________________________________ How many? ___________ What Kind? ___________________________________________________________ _____________________________________________________________________ |
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If "yes" are they spayed or neutered yet? ______________ |
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If "yes" are they currently on heartworm preventative? __________________ |
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If "yes" are they indoor or outdoor? __________________ |
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Please describe your pets in detail including gender: |
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If you have owned pets in the past and do not now, what happened to them? |
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Placement Information
Are you looking for primarily an indoor animal or primarily an outdoor animal? _______________
Please describe where the animal will stay when you are at home:
Please describe where the animal will stay when you are away:
How many hours per day will the animal be alone? ___________
Do you have a crate? _______________
If "yes" how many hours per day will the animal be crated? __________
What kinds of solutions would you be willing to try
if housebreaking accidents occured?
(please check all that apply)
crate animal door leave outside none, I would need to return the animal
other solutions (specify)
References
Please provide us with your current veterinarian information:
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Name |
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Address |
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City |
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Phone |
Please provide three references that are not related to you:
Reference #1
Name
(day phone)
(evening phone)
Reference #2
Name
(day phone)
(evening phone)
Reference #3
Name
(day phone)
(evening phone)
And Finally...
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Do you have a gender preference? |
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Age preference? |
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Is there a animal on our web page that you are especially interested in? |
____________________________________________ ____________________________________________ |
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If you were referred by anyone, please tell us so we may thank them: |
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Please give us any other information that may help us make the best match for you and your new pet: |
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