Name:  _________________________________________________________________

Address:  _______________________________________________________________

City:  _________________________ State:  ______________Zip:  _______

Phone:  ________________________E-Mail address:   _________________________

Employer: ________________________________________

List the age/breed of your current Animals.  ________________________________________________

Are these animals spayed/neutered?   Yes/No

Do you have a fenced yard?  Yes/No Would you be willing to provide a fence or run?  Y / N

Number of adults in the household?  _____ Number of children & their ages?  ________

How many hours will the dog spend alone daily? _____
Are you agreeable to a home visit?  Yes/No

If you rent your home please supply the address and phone number of your landlord:  __________________________

What will you do with the dog when the family is on vacation? ____________________________

Do you have a preference for a male/ female? 

Name AND Phone # of your veterinarian:  ______________________________________

Name and phone # of 2 personal references:___________________________________

Signature:_____________________________________ Date: _________________