How many hours a day are you away from home?
Are there children in your home? Yes No If yes, what are their ages?
Is acquiring a new dog a family decision?  Yes No  
Should your current family/home situation change, will the pet be a part of that change? Yes No   

If your pet would not be a be a part of that change, please explain below.

II. Tell us about your home:

What type of home do you have?  Single-family house Mobile Home Duplex Condominium Apartment Farm
Do you own or rent your home? Own Rent Do you have roommates? Yes No
What size yard do you have?
Is your yard fenced? Yes No
Do you intend to use a pet door? Yes No
Where will your new dog sleep at night?
Where will your new dog stay while you're not at home?

For Renters: (For entries below - If you do not rent please enter "None or No" in this section.)
Landlord's name:
Landlord's phone number (plus area code):
Weight or size restriction for pets, if any:
Do you have a pet deposit? Yes No If you have a pet deposit, have you paid it? Yes No
Do you intend to be a single-pet family or multiple-pet family? Single Multiple
Are your roommates ok with you bringing in a new pet? Yes No

III. Tell us about your other pets (list the pets that you have owned in the last five years or still have):

Are all pets in your home up to date on their vaccinations? Yes No
Distemper? Yes No    Bordatella? Yes No    Parvo? Yes No
Heartworm Preventative? Yes No

Your Veterinarian: (For entries below - If you do not have a veterinarian please enter "None or No" in this section.)
Please give us your veterinarian’s name and phone number for confirmation:
Practice: Vet’s Name:
Vet's Phone (plus area code):

If any other pets live at your home please list them below (pet's name and species) along with their owner's name, their veterinarian’s practice, veterinarian’s name and veterinarian’s phone number.

IV. We will need at least two (2) personal references and their phone numbers.

Name Phone (plus area code):