Name of animal of interest:*
How did you hear about us?
What type of dog/cat are you looking for?*
What activity level are you looking for in a dog?*
How many hours per day will this dog/cat be home alone?*
Where will you keep this dog/cat when home alone?
Where will this dog/cat sleep?
What percentage of time will this dog/cat spend outside?*
How much do you think food, supplies, vet care, etc. will cost monthly?*
What would you do if your dog required an expensive veterinary procedure?
Current pet's name in home*
Pets Kept Inside or Outside?*
How many pets have you owned in the last 5 years?*
Where are those pets now?*
What, in your opinion, would be a reason for giving up a pet?
Have you ever surrendered a pet to a shelter, other agency, or another person?*
Do you know what heartworm disease is?*
If yes, please state how dogs get heartworm disease and how it is prevented.
How do you plan to prevent fleas and ticks?*
Which of these best describes your household?*
Does your landlord require a pet deposit an/or monthly pet "fee"? *If applies*
How many adults live in your household?*
Relationship to you of each adult living in your household*
Age of children living in home*
Do you have a completely fenced back yard?*
If no, what will you do for the animal's elimination and exercise requirements?*
If you had to be away for a lengthy period of time (vacation, emergency, or work travel), who will take care of your dog while you are away?*
Have you used a veterinarian in the past?
Veterinarian's Phone Number*
How long has this been your Veterinarian?
List animals you have taken to your Vet in the past 3 years:
May we contact your Vet for a reference?*
Reference #1 Phone Number*
Reference #2 Phone Number*
Do we have permission to contact your references?*
Would you agree to a home visit by a representative of our organization?*
Is there anything else you would like to tell us?