Spouse: Age:
Address:
City: State: Zip Code:
Email Address (example: [email protected] <mailto:[email protected]>):
Home Phone:
Your Employer: Work Phone:
Number of Children/Grandchildren: Their Ages:
How long have you lived at your current address?
Do you: (Circle one) Own Rent Other
If Other, Please explain:
If Rent, Name of Landlord:
Landlord�s Phone:
Current housing: House Condo/Townhouse Mobile Home Apartment
What type of environment? : Urban Suburban Rural
If less than two years at current address please list previous address:
Does your Current home have a yard? Yes No
Is it fenced: Yes No What type of fence and how tall? :
Adoption Information
Which member of you household will feed and care for this animal?
Is someone home during the day? (Circle One) Yes No
If No, where will the dog stay while you are gone?
This animal will be alone for how many hours a day? hours
When you do go away for a few days, who will care for this animal?
Where will your dog be kept most of the time?
Will you take your dog to obedience class? Yes No Why not?
Have you ever owned a Yorkie? Yes No
If Yes, where is that Yorkie now?
Do you prefer Male Female Either Explain your choice on back.
Age range? NOTE: WE NEVER EVER GET PUPPIES IN RESCUE! ___ years to ___ years or doesn�t matter.
Would you consider adopting more than one if they came together? Yes Maybe
Have you ever given up a dog or taken a pet of yours to a shelter? Yes Explain on back
Will you provide a Foster Home? (Circle One) Yes No This is VERY Important! Please consider this question carefully. All of our dogs go to foster homes FIRST before they are adopted. The foster family always has first right of refusal to keep and adopt the dog. It is the best way to find out if the dog is compatible with your family. If you have questions about fostering; please ask.
Other Pet Information
Do you have other pets? Yes No
If Yes, list type (breed, age, sex):
Are all other pets current on all vaccinations? Yes No
Are your other pets spayed/neutered? Yes No
Are your animals on Heartworm preventative? Yes No
If Yes, what type? :
Veterinarian�s Name: Phone:
Name that animals are under at the vet�s office (pet�s name and owner�s name)
Approximate date of you current pet�s last office visit:
List the pets you have owned in the past three years and what happened to them:
List any Humane Societies, Organizations, Breed or Training Clubs you are associated with:
