Today's Date:	* required
Contact information:
First name:	* required
Last name:	* required
Mailing address:
Email address:	* required
Home Phone:	* required
Alternate Phone:	* required
Best way to contact you:	e-mail home phone alternate phone
What type of home do you live in?	House Condo Apartment Mobile Home Dorm
About Your Home:
Do you Own, Rent, Other?	own rent other
If you rent, please answer the following 4 questions.
1.      Does your rental agreement allow for dogs?	yes no n/a
2.    How much is your pet deposit?	* required
3.       Landlord Name:	* required
4.       Landlord Phone Number:	* required
Do you have a fenced in yard?	Yes No
Height of fence?	* required
Type of fence:	* required
About your family:
How many adults live in your home?	* required
Do you have any children living in your home?	* required
If yes, how many and what are their ages?
Is anyone living in the home allergic to dogs?	* required
Please list all pets you currently own.  Please include name, type and age:
Please list pets you have owned in the past 5 years. Please include name and type.
What happend to the pets you no longer own?
Your Veterinarian:
Please provide information veterinary clinics who have provided medical care for your pets past and present.  (Out of State veterinarians are ok)
Name of Veterinarian or Clinic:	* required
Veterinarian phone number:	* required
If required, will you call to give permission to release information about your pets?	yes no
What owner name are the pets listed under?	* required
Pet Preferences and Care:
Why do you want to own a new pet?
Do you understand that owning a pet can be a commitment of 10 to 15 years?	yes no
Which pup are you interested in?	* required
Where will your new pet live?	Mainly Inside Mainly Outside
How much time will your new pet spend alone?
Where will your new pet stay when alone?
Where will your new pet sleep?
Do you consider pets part of the family?	Yes No
Will you have your new pet spayed/neutered?	yes no
Will you take your new pet to obedience classes?	yes no
How will you control fleas and heartworms?	Heartworm preventative Flea preventative Both None
Are you financially prepared to give your new pet routine medical care? (food, Yearly check-ups and shots, monthly flea and heartworm preventative)	yes no
What circumstances would cause you to give up your pet?
Is there any additional information you would like to provide?
Personal References:
Reference #1 Name:	* required
Phone Number:	* required
E-Mail:	* required
Reference #2 (not a family member) Name:	* required
Phone Number:	* required
E-Mail:	* required