First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County*

Country

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'.*

In what type of home do you live?

Do you own or rent your home?*

If you rent, please enter your landlord's name and phone number. If not, enter N/A.*

If you rent, have you received the approval of your landlord to have an animal? (Copy of Rental Agreement is required for renters. If you Own, enter Yes.)*

Do you have a secondary residence?*

If yes, where?

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).*

Is your yard fenced?*

If no, how will you safely contain your Brittany?*

What type of fence?

Other fence type:

What is the height of the fence?*

Is there a pond or pool on your property?*

Do you have an outdoor kennel or run?*

Will your dog be supervised while outside?*

Will your dog be tied out on a cable or chain?*

If so, for how long?

Have all adults in the home agreed to adopt a rescued Brittany?*

How many hours each day will the animal spend alone?*

Will the animal be kept inside or outside?*

Where will the animal sleep?*

How many Brittanys have you owned?*

Are you interested in a specific dog? Please list the dog's name and ID number and the coordinator listed in the dog's write-up.

What are you looking for in a Brittany? (To select more than one option, hold down the Control key when you click with your mouse.)
Choose all that apply: Male Female Puppy Young Adult Senior Special Needs Brittany mix Full tail Bonded Pair Under 50 pounds Over 50 pounds

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

What traits are you looking for in a pet? (To select more than one option, hold down the Control key when you click with your mouse.)
Choose all that apply: Calm Cat friendly Cuddles Dominant Easy to train Energetic Family Pet Housebroken Hunting Instinct Independent Kid Friendly Knows basic commands Lazy No Barking No Shedding No jumping Stubborn Submissive Tireless Velcro Dog

Have you applied with any other rescue?*

If yes, with whom?

Have you ever been denied by another shelter/rescue?*

If so, why?

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)