Name:
Address:
City:
State:
Zip
Code:
Phone:
Work Phone:
Cell Phone:
Email:
Name of pet(s)
you are interested in:
How did you hear about
us?
Petfinder
1-800-save-a-pet
From
a friend
Other
ABOUT
YOUR HOUSEHOLD
Do you have children or grandchildren
who live with you?
Yes
No
Number of children
Childrens' ages:
Please list other residents in your
household:
Are all the pets present
in your household up to date on their
vaccinations?
Yes
No
Are ALL household members
in complete agreement in adopting/caring
for the dog?
Yes
No
Do any of your family
members have allergies?
Yes
No
ABOUT
YOUR HOME
What type of home do you live in?
Own Home
Rent Home
Condo/Townhouse
Apartment
Mobile
Home
Other
If Other-
How long have you lived
at your present address?
Years
Months
If you rent, do you
have the permission of your landlord
to keep a dog?
Yes
No
Your landlord's name:
Your landlord's phone:
May we have permission
to contact your landlord?
Yes
No
Do you have a doggie
door?
Yes
No
Do you have a fenced
yard?
Yes
No
Please describe the
fencing:
Block
Wood
Chain
Link
Invisible/Underground
Other
If other-
YOUR
EXPERIENCE WITH PETS
I consider myself:
an
experienced dog owner
somewhat
experienced
novice
dog owner
Please describe any
pets you currently have:
Have they been spayed/neutered?
Yes
No
If you owned a dog before,
what happened to your previous dog(s)?
If your previous pet(s) died, give
age and cause of death:
Have you ever had to
relinquish a dog?
Yes
No
If yes, what were the
circumstances?
If you have current
pets, or have owned a pet before,
may we contact your veterinarian?
Yes
No
Veterinarian
name:
Veterinarian
phone:
Please provide at least
one other reference. Name:
Reference
phone:
Reference
relationship to you:
CARING
FOR YOUR DOG
Who will be the primary caretaker
of your dog?
How long are you gone
each day?
Where will the dog sleep at night?
Where will the dog be housed during
the day when you are home?
Where will the dog stay while you
are gone during the day?
How often do you travel?
When you travel, who will care for
the dog?
How will you exercise the dog?
How much adult supervision of dog
and child will be provided?
With neighborhood children?
How much responsibility will your
child/children be given in the care
of the dog?
Are you willing to take your dog
to a veterinarian for an annual physical
and vaccinations?
Yes
No
Are you willing to have your dog
tested annually for heartworms and
provide monthly heartworm prevention?
Yes
No
Are you willing to provide
regular flea/tick control?
Yes
No
A
DAY IN THE LIFE...
Describe
what a typical day will be like for
this pet if he/she is adopted by you:
COMMENTS
GENERAL
AGREEMENT: I am at least 21 years
of age. All of the information I have
given is true and complete. I understand
that BBCRA has the right to refuse
my application.