First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County

Email*

Home Phone*

Work Phone
x

Cell Phone*

Alt Email

Text/Pager Email

Please provide name and phone number of who we should contact in the event of an emergency.*

How did you hear about us?*

How many people reside in your household?*

What are the ages of all household members?*

What is your status?*
Choose one: Co-habitant/roommate Domestic partner Married Single

What are your current pets' names, ages, gender, breed/species? If none, reply 'no pets'.*

Do you have a veterinarian?*

If yes, please provide the name of your vet/clinic/hospital and telephone number. Also list names of pets they have cared for. Be sure to call the vet office granting an NBRAN coordinator permission to do a vet check. If no, please enter at least one personal reference (name and telephone number).*

Have you ever owned a Brittany?*

How many Brittanys have you owned?*

Is your yard fenced?*

What type of fence?

What activities are/were you and your dog involved in? (To select more than one option, hold down the Control key when you click with your mouse.)
Choose all that apply: Agility Conformation Hunting Obedience Rally Walking/Hiking Other None

Are you or have you been involved in other rescue efforts? If yes, please explain.*

What area(s) of Brittany rescue would you be interested in? (To select more than one option, hold down the Control key when you click with your mouse.)
Choose all that apply: Foster Care Home Visits Organization/Management Shelter Contact Training Transportation (Canine Railroad)