First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Animal Name*

Dog Breed*

Dog Sex
Choose one: Female Male

Dog Age*

Length of Ownership*

How long can you keep the dog*

If applicable, where did you adopt this animal from? *

Is the dog Spayed or Neutered*
Choose one: Yes No

Dog Up to Date on Vaccinations*
Choose one: Yes No

Is Dog Microchipped*
Choose one: Yes No Unknown

Microchip Number

Veterinarian's Name

Vet Address

Vet City

Vet Phone

Is dog good with Strangers*
Choose one: Yes No Unknown

Is dog good with Kids*
Choose one: Yes No Unknown

Does your dog live with children?

What ages of children has your dog interacted with?

Is dog good with other Dogs*
Choose one: Yes No Unknown

Does your dog live with other dogs?

How does your dog greet other dogs? Ready to play/need sometime to warm up/etc.

Is dog good with Cats*
Choose one: Yes No Unknown

Does your dog live with cats?

Describe any previous training the dog has had*

What commands does your dog know?

Is your dog crate trained (can they be kenneled while you go away)?

Is your dog potty trained?

Describe dogs daily exercise*

What is your dogs energy level?

Does the dog have a bite history*
Choose one: Yes No

Please describe any bite history

Describe any behavioral issues

Describe any medical issues

Reason for surrender*

Do you have any comments or questions

I certify that the information entered on this applicant is true. Enter your name and date*