* Required
* First Name
* Last Name
* Phone
Mobile
Fax
Evening Phone
* Occupation
* Email
* Address
* City
* State/Province
* Zip
* Adults In Household
* Number of Children In Household
* Ages Of Children
Pets Currently Owned
Current Pets Spayed Neutered --None--YesNo
Reason For Not Getting Dog Fixed
Family Support --None--YesNo
Prior Experience Owning a Dog
Given Up Dog Before --None--YesNo
Reason For Giving Up Dog
Description of Dog Looking For
Consider Pair of Dogs --None-- Yes No
Age of Dog Interested In (Hold Ctrl to select multiple items) --None-- Puppy 0-3y 4-7y 8-10y 10+y
Do you need a dog that is good with other dogs?
Do you have a pool?
If yes, is it fenced?
Description of Yard and Fence
Your live in a(n) --None-- House Apartment
Permission to Visit Home --None-- Yes No
Own or Rent --None-- Own Rent
Permission From Landlord --None-- Yes No
Landlord's Name
Landlord's Phone
Specific Dog From WebSite
Gender Interested In --None-- Male Female No Preference
Breed of Dog Interested In --None-- Pure Breed Mixed 4-7y Any
Color of Dog Interested In (Hold Ctrl to select multiple items) --None-- Blonde Gold Black Red
Do you need a dog that is good with cats?
Do you need a dog that is good with kids?
Where Will Dog Sleep
Number of Hours Dog Left Alone
Where Will Dog Be Left Alone
Current Veterinarian
Allegeries --None-- Yes No
