Date:
Me and My Family
Applicant's Name:
*
Street Address: *
Apt #:
City: *
State: *
Zip: *
Home Phone:
Mobile Phone:
Work Phone:
Email Address: *
Occupation(s): *
Questionnaire
Name or type of dog
seeking: *
Reason for selecting this particular dog or breed: *
Name and ages of all household members, including yourself: *
Who will be caring for
the pet? *
Describe your current pets:*
(Due to the many health benefits accruing from spay and neutering,
as well as to prevent accidental liters, we require that all
resident pets must be spayed/neutered.)
(1) Name: Spayed/Neutered
Yes
No
N/A
Male Female Age:
Type:
Dog
Cat
Rodent
Fish
Turtle
Horse
Bird
Goat
Pig
Other
Choose One
(2) Name: Spayed/Neutered
Yes
No
N/A
Male Female Age:
Type:
Dog
Cat
Rodent
Fish
Turtle
Horse
Bird
Goat
Pig
Other
Choose One
(3) Name: Spayed/Neutered
Yes
No
N/A
Male Female Age:
Type:
Dog
Cat
Rodent
Fish
Turtle
Horse
Bird
Goat
Pig
Other
Choose One
(4) Name: Spayed/Neutered
Yes
No
N/A
Male Female Age:
Type:
Dog
Cat
Rodent
Fish
Turtle
Horse
Bird
Goat
Pig
Other
Choose One
(5) Name: Spayed/Neutered
Yes
No
N/A
Male Female Age:
Type:
Dog
Cat
Rodent
Fish
Turtle
Horse
Bird
Goat
Pig
Other
Choose One
How many hours will pet(s) be alone during the day? *
Where will the dog be kept during this time? *
When I am home, my dog will mainly be: *
Where will the dog sleep at night? *
Do you have a fenced yard? *
Yes
No
What kind of fence *
Wood
Chain Link
Other
N/A
Fence height? *
1 ft
2 ft
3 ft
4 ft
5 ft
6 ft
7 ft
8 ft
9 ft
10 ft
10+ ft
N/A
If you currently have other pets, or if you previously had pets in your adult life
(within the past 5 years), please provide your Veterinarian's information: *
Veterinarian Name:
Veterinarian Phone Number:
How long have you lived at your current address? *
Type of Housing? *
House
Condo
Apartment
Mobile Home
RV
Ranch
Other
Choose One
Own Rent Other Arrangements
Name of apartment complex or trailer park:
Do they allow pets?
Yes
No
N/A
Name of Manager/Landlord:
Contact phone number for Manager/Landlord:
Any restrictions on pets?
Yes
No
N/A
If yes, explain restrictions:
Do you ever have relatives or friends visit with their pets? If so what type of animals visit? Please be specific:
Have you had any other pets in your adult life? *
Yes
No
Choose One
If yes, how long did you own them and what happened to them? *
Are you planning on moving in the near future? *
Yes
No
Choose One
If you move, what would you do with your pet? *
Do any members of your household have pet-related allergies?
Yes
No
Choose One
Please list 2 personal references including phone numbers:
*
(1) Name: Phone Number: Relationship:
(2) Name: Phone Number: Relationship:
Have you adopted any pets from another rescue or animal shelter in the past? *
Yes
No
Choose One
If yes, which one(s)?
Have you volunteered with a rescue or animal shelter in the past? *
Yes
No
Choose One
If yes, which one(s)?
I am interested in a (check all that apply): *
Puppy Adult
Senior
Male
Female
How long have you been looking for a pet?
I want a pet because... *
What is the activity level of the dog you are looking for? *
What do you consider undesirable traits? *
What would you do if you saw some of the above listed traits displayed in the pet that you have adopted?
*
What will you do if the dog displays bad behavior such as barking, digging, chewing, etc?
*
What time period do you require to prepare for your new dog? * days
None, Ready Now!
Do you or any of your neighbors have livestock?
Yes
No
Choose One
Who will be responsible for the socialization, medical care and training of this animal?
*
Would you be interested in attending training sessions? *
Yes
No
Choose One
Who will be housebreaking this pet?
*
Describe your method of housebreaking:
*
In what manner will you be transporting your pet in your vehicle?
*
What brand of food will your dog eat?
*
What grooming requirements do you feel are necessary for this particular dog?
*
On average, how much do you expect to spend annually on this dog? (Including heartworm preventative, flea/tick preventative, vetting, toys/treats, grooming, etc.)
*
There are times when unexpected and often very expensive medical conditions occur. What will you do if this happens to your pet?
*
Would you be willing to allow a representative of the organization to visit your residence? *
Yes
No
Choose One
How did you find out about our Organization? *
Newspaper Ad Internet
Friend
Volunteer with our group
Television
Meet-n-Greet
Would you consider volunteering for our group? *
Yes
No
Choose One
If you can help, in which of the following areas?