Name (Guardian) *

First Name

Last Name

Cell Phone *

(###)

###

####

Alternate Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Vet Phone *

(###)

###

####

Personal Reference Phone *

(###)

###

####

Rent / Own *

Rent

Own

Fenced yard *

Yes

No

Spayed /Neutered *

Yes

No

Do you own a pickup truck? *

Yes

No

Activities you participate in that will include your dog? *

Hiking

Hunting

Camping

Walking

Couch Potato

Running

Agility

Frisbee

Biking

Other

Have you had previous experience with rescue dogs? *

Yes - if so explain below

No

Gender preference *

Male

Female

No preference

Preferred temperament *

Mellow

Moderate energy

Playful

Active

When are you prepared to adopt? *

Now

Later

Date (specify below)

Adoption date

Choose the earliest time period

MM

DD

YYYY

Do you agree to a home check? *

Yes

No

Date

MM

DD

YYYY