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Name of Dog:
Breed:
Date:

Name:
Spouse:
Address:
City:
State:
Zip Code:
Home Phone #:
Work Phone #:
Cell Phone #:
Email Address:

Type of Residence:   House
  Apartment/Condo
  Townhouse
  Mobile Home

Own or Rent?
  Own        Rent
 
Does your home have a fenced yard or underground fencing?   Yes        No
 
Location:   Urban
  Suburban
  Residential
  Rural
  On Acreage
How many household members?
List ages of any children under 18 (N/A if none):


Are you or another member of your household presently employed?  Yes
  No
  Unemployed
  Retired
  Student
Current/Past Vet Clinic:
Vet Phone #:

Have you owned any pets within the last ten years?   Yes
  No


Why are you choosing to adopt a dog and are all members of the household in agreement with this decision?
What role will this dog play in your family?
Which family member(s) will be primary caregiver(s) for your new pet?
Please describe any specific traits you are looking for in an adoptive dog:
How many hours per day will the dog be left alone and when left alone, where will the dog stay?
Where will the dog be during nighttime hours?
Will you allow the dog to run off leash? If so, where?
What is your understanding of the routine veterinary care necessary to maintain a healthy animal?
Some rescue dogs have been traumatized and often exhibit behavior issues when introduced to a new environment. These behaviors may include but are not limited to:  Hand- shyness, jumping, chewing, resource-guarding, scent-marking, inappropriate elimination, separation anxiety.

Describe your plans for mitigating these behaviors if they occur:
Exercise, play and socialization are important to a dog’s general wellbeing. How will you fulfill this need?
If you have plans to go out of town or on vacation, what will you do with your dog?
If you had to move or your circumstances changed, what would you do with your dog?
If you have any additional information you would like for us to consider or any comments, include here: