Name: ________________________  Spouse’s: ___________________ Date: __________

Address: ________________________________________________________________ 

City: ____________________ Zip: _____________ Phone:  ________________________

Work: ____________________ Cell:   _____________________

Circle One The above address is: House    Apartment/Condo    Trailer   or   Modular

Do you: Own     Rent      Live with someone

Landlord’s name, address and number: __________________________________________

________________________________________________________________________

Do the other members of your household know you want this pet: Yes   No

Will this pet be an: Inside pet Outside pet Both

Where will the pet be when no one is home: Outside      Inside        a crate    

Inside with run of house Other _________________________________________________

Have you owned a pet before: Yes  or  No

Do you have other: Dogs # _______ Cats # _______ Other _________

May we contact your previous vet: Yes     No         

Name of Veterinarian: _________________________  Phone # of Vet:   _________________

Have you ever had to find another home for a pet: Yes   No

If yes, why_________________________________________________________________

What happened to your last pet:   _______________________________________________

In the past 6 months, have you had a pet that contracted parvovirus, leukemia,

or an unknown illness: Yes     No    If  yes, why ______________________________________

Why do you want this pet: _____________________________________________________

Are you willing/able to provide vet care such as vaccinations, spay / neuter: Yes      No

Place of Employment: _________________________________________________________