Date:   

Type of dog desired:         

Color(s):         

Why do you want a dog? 

Will the dog be used as a guard dog? 

Age of dog desired:         

Oldest dog considered:         

Approx. weight as

 an adult dog:         

Your Name:                 

Address:       

City, State, Zip:          

Your Age:                                                                                        Spouse’s Age:       

Number of children?                                                                         Ages:       

Telephone numbers:          (home):                                             (work):           

Type of residence:                 House/Own                      House/Rent     Apartment        Condo               Townhouse

How long have you lived at this address?       

If rental, are dogs allowed?:                Yes     No

Size Restrictions?                 Yes     No

Max. Size:        

Complex name/address:         

Manager/Landlord:         

Phone number:         

Current housing location:                    City Limits                                         Outside City Limits

Type of street:               Very busy road         Slight traffic         Residential area      Country road

Speed limit:        

Does your home have a yard:                             Yes                     No

Does your yard have a fence:       Yes             No       Will the gate be locked with a pad lock?       Yes       No

Does your yard have a run / doghouse?        Yes                        No          If no, will you provide one?         Yes          No

Where will dog live?        Inside only              Outside only     Mostly inside             Mostly outside

Where will the dog spend nights?     Inside                 Outside

Will you allow the dog to run loose?                                  Yes     No

If Yes, where?         

How many hours per day will the dog be alone?          

Where will the dog stay when left alone?        

Have you ever housetrained a dog?  How?       

How many years do you plan to keep the dog?       

Under what circumstances would you give up your dog?       

Have you had pets in the last five years?    Yes     No

  If yes, complete the following chart

Type of Pet

Years Owned

Spayed/Neutered

Inside/Outside

Where is Pet Now?

   Yes     No

   Inside     Outside

   Yes     No

   Inside     Outside

   Yes     No

   Inside     Outside

   Yes     No

   Inside     Outside

   Yes     No

   Inside     Outside

Do you agree to spay or neuter this dog if it has not been done already?    Yes   No

Are you willing to pay for a heartworm test?    Yes       No

Are all other pets in the house current on vaccinations?      

How do you feel about obedience classes?      

Current or past vet name of clinic:         

Phone:        

Do you consider your dog a part of the family?         Yes     No

Will your dog be on heartworm prevention?    Yes    No

Are you aware that a dog is a large and lifelong commitment?       Yes           No

How did you hear about us?         

Email Address: