First Name*
Last Name*
Address*
City*
State/Province*
Zip/Postal Code* -
Email*
Home Phone*
Cell Phone
Name of dog you are interested in (if more than one, please select first choice and list any others in the comment box at the end of the form): Choose an animal: Airka Barney Bernie Bonita Bower Brutus Cecilia Daisy Ebony *our favorite black beauty* Eddie *Loves other dogs!!!* Faygo *fostered with dogs, cats and kids* Harper Jupiter Lamar *LOVES DOGS* Lelu *Pint Sized Princess* Max Max- *GORGEOUS ADULT BOY* Neptune Princess Penny *Excellent House Manners* Punky B *BESTEST GIRL* Shortcake Spice Stevie Nicks *Fostered with Dogs and Cats* Strawberry Susan Tig *THE BEST BOY* Tulip Venus Waldo
Primary Adopter Employer*
Primary Adopter's Work Phone
Secondary Adopter's First Name
Secondary Adopter's Last Name
Secondary Adopter Phone
Secondary Adopter's Email
Name of friend we can contact if your dog is found and you cannot be reached*
Phone Number*
How many adults reside in your home?*
How many children reside in your home?*
What are the ages of the children?
Do you:*
If "Other", please explain
If "Rent", please provide the name of your rental office or landlord
If "Rent", please provide the phone number for your rental office or landlord
If "Live with parents", please provide a parent's name
If "Live with parents", please provide a parent's phone number
Type of housing*
How will you contain this dog when it is outside?
How many hours a day will the dog be left alone?*
Please list dogs you've owned in the past five years, starting with current or most recent:
Dog Number 1
Breed
Age
Spayed/Neutered?
Up to date on shots?
What happened to this animal?
Dog Number 2
Spayed/Neutered
Dog Number 3
Name of your veterinarian
Please provide the name of any trainers you have worked with.
If you have ever had to surrender a dog to a friend, shelter, or pound, please explain why*
What behaviors in a dog would you find unacceptable (such that you would want to return the dog)?*
If you don't have one of our specific dogs in mind, please describe the type of dog you are looking for
Additional comments, questions, or concerns
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