| Full Name: | |
| E-mail Address: | |
| Street Address/City/State: | |
| Zip Code: | |
| Home Phone: | |
| Best time to call: | AM |
| PM |
| Work Phone | |
| May we call you at work? | Yes |
| No |
| Spouse / Partner name | |
| Do you have children? | Yes |
| No |
| If so, what are their ages? | |
| Which dog are you are interested in? | |
| Is anyone in the house allergic
to animals? | Yes |
| No |
| If so, please explain briefly: | |
| Do you have a veterinarian
you have used in the past, and plan to use with this Dog? | Yes |
| No |
| If so, what is the Vet's Name? | |
| Street Address/City: | |
| State | |
| Zip Code | |
| Vet's Phone number | |
| Vet's Office Hours | |
| Type of home you live in | |
| If other, please explain | |
| If you rent, can you furnish a notarized letter from
your landlord, granting you permision to keep this Dog? | |
| Is your yard fenced? | |
| If not, how will this Dog get exercise
and relieve itself? | |
| Is there someone at home during
the day? | Yes |
| No |
| If not, how many hours per day/week will the Dog be
left alone? | |
| Have you owned a dog in the
past? | Yes |
| No |
| Do you currently own pets? | Yes |
| No |
| Type/Breed/Age of pet(s)? | |
| Are your pets spayed/neutered? | Yes |
| No |
| If No, why not? | |
| Please provide the Name, Address (includeing
street, city, state) and Phone Number of 2 people, not related to you, who can recommend you as a good adoptive family for
a rescued Rat Terrier. | |
| |
