Name

Dog you are interested in

Email

Address

City/State/Zip

Phone numbers

Number of people in home & ages

Household pets by breed, age & gender

Household pets current on vaccinations? Yes No

Current pets spayed/neutered? Yes No

Would you take a cattle dog mix? Yes No

Special needs dog? Yes No

Do you own your home? Yes No

Do you have a fence? How high?

Do you have a doggie door? Yes No

Do you have a pool? Is it fenced?

How long are you home during the day?

Reference #1 (Name & Number)

Current Veterinarian (Name & Number)