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| NAME: _____________________________________________ |
| ADDRESS:___________________________________________ |
| CITY:__________________ STATE: ______ ZIP: ___________ |
| EMAIL ADDRESS: ____________________________________ |
| HOME PAGE (if you have one) : __________________________ |
| HOME PHONE: _______________________________________ |
| WORK PHONE: _______________________________________ |
| VETERINARIANS NAME & NUMBER: ______________________ |
| MAY WE CONTACT YOUR VET FOR A REFERENCE?___________ |
| PLEASE LIST TWO PERSONS (NON RELATIVES) THAT WE CAN CONTACT FOR A REFERENCE: (Name and phone #) |
| 1) _________________________________________________ |
| 2) _________________________________________________ |
| DO YOU HAVE ANY DOGS? _______ HOW MANY? __________ |
| WHAT BREED/S OF DOGS DO YOU PRESENTLY HAVE? ___________________________________________________ |
| DO YOU HAVE ANY OTHER PETS (CATS, BIRDS,ETC)?________ |
| DO YOU HAVE ANY CHILDREN?________ AGES: ____________ |
| HOW MANY PEOPLE LIVE IN YOUR HOUSEHOLD? __________ |
| WILL THE NEW PET BE KEPT INSIDE?____________________ |
| DO YOU HAVE A FENCED IN YARD?______________________ |
| WHAT KIND OF DOG ARE YOU INTERESTED IN? DID YOU SEE A PARTICULAR DOG ON OUR WEBSITE THAT YOU ARE INTERESTED IN? ___________________________________________________ |
| DO YOU PLAN TO TAKE YOUR NEW DOG TO OBEDIENCE CLASSES? __________________________________________ |
| ARE YOU ABLE TO HOUSETRAIN YOUR NEW PET IF NEEDED? ___________________________________________________ |
| WILL YOU ACCEPT A COLLECT CALL CONCERNING THE ADOPTION? _________________________________________ |
| HOW DID YOU FIND OUT ABOUT US? ___________________ |
| ARE YOU ABLE TO TRAVEL TO PICK UP YOUR NEW PET OR WILL YOUR NEW PET NEED TO FLY TO YOU? ___________________________________________________ |
| WHAT IS THE NEAREST MAJOR AIRPORT FOR YOU? ___________________________________________________ |
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| E MAIL TO : [email protected] |
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| SNAIL MAIL: Rebecca Robinson |
| 309 S Windom |
| Wayne, NE 68787 |
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