Pet's Name:
Your Name:
Company:
Home Phone:
Fax:
E-Mail:
Address:
City:
State/Zip:
Cell Phone:
Work Phone:
Your Occupation:
Work Hours:
Number of persons in household:
Applicant's age:
Number of children:
Age of children:
Name of Spouse or Room-Mate:
Occupation of Spouse or Room-Mate:
How long at present address:
Rent
Own
Landlord's Name:
Landlord's Phone No.:
Please Select One ---->
House
Townhouse
Condominium
Trailer
Apartment
Please Select One ---->
All the time
At night
In and out
never
other(specify below)
If other, specify:
When would the dog be outside?:
Please Select One ---->
All the time
At night
In and out
never
other(specify below)
In what areas would the dog be allowed?
What rooms are off limits to the dog?
Where do you plan to put the food/water dishes?
How many hours of the day would the dog be alone?
Does your property have a yard?
Yes
No
If Yes explain what type fence and condition:
Where would the dog sleep at night?
Will the dog wear an ID tag, Tattoo and or Micro-Chip:
Yes
No
What type collar will the dog wear?:
Please Select One ---->
leather buckel
nylon buckle
nylon adjustable collar
choke collar
pinch or spike collar
harness
electronic or radio collar
Yes
No
If so, where do they sleep?
Whom is the dog for?
Who will be responsible for taking care of the dog?
Yes
No
Why do you want the dog? Check all that apply:
Companion for you
Companion for other family member
Protection
Hunting
Guide/Search Dog
Companion for other pet
How do you plan to provide for the dog when you are out of town?
What would you do if you had to move and trouble finding a place that allowed dogs?
What would happen to the dog if you had to relocate out of state or overseas?
If the dog chews your furniture or carpet, what would you do?
What would you do if the undesirable behavior continued?
Under what circumstances would you not keep the dog?
What would you do in that event?
Yes
No
How do you rate your dog experience?
1st time owner
Beginner
Intermediate
Advanced
Other:
What would you do if you or your spouse became pregnant?
Find the dog another home
Keep the dog
Return the dog to Pets Haven
Make the dog an outdoor dog
Which of the following reasons would prompt you to give up your dog? (choose all that apply)
Excessive Barking
Biting/Scratching Family Member
Moving
Poor Guard Dog
Planning on Having a Baby
Allergies
Not Friendly with Guests (barking, hiding)
Aggressive with Dogs/Cats
New Spouse/Partner doesn't Like Dog
Biting
Chewing on Furniture or Carpet
Divorce
Shedding
Financial Problems
Won't always go outside to pee
Excessive Veterinarian Bills
Aggressive with other dogs
Dog's Health Problems (Arthritis, Overactive Thyroid, Urinary Tract problems, Hip or Elbow Dysplasia etc.)
None of the above
Yes
No
Yes
No
If yes, why?
Yes
No
If any pets are not spayed/neutered, explain why?
Yes
No
Name and City of Veterinarian:
Phone # of Veterinarian:
Yes
No
Why do you want this particular dog?
Please indicate all dogs and cats you have owned in the past. List "Type of Pet", "Years Owned", "What happened to the Pet?
Cause of death.
Please indicate all pets you presently own. List "Type of Pet", "spayed/neutered", "age", "length of ownership":
If there is any other relevant information you would like us to know, please list below:
