Date:09/05/10
Applicant 1
First Name / Last Name:
Occupation:
Applicant 2
First Name / Last Name:
Occupation:
Contact Information
Address:
City/State/Zip:
Home Phone: xxx-xxx-xxxx
Cel Phone: xxx-xxx-xxxx
Work Phone: xxx-xxx-xxxx
Email:
Current Household Information
How long have you been at your present address? Own Rent
How many children living at home are...Under 5? 5 - 12? Older than 13?
What type of fence do you have?
Why do you want to own a rescue dog?
How soon do you hope to adopt?
Have you owned a dog before?Yes No
   If so, what breed?
   What happened to him/her?
Do you currently have other dogs?Yes No
If yes, please list them below:
BreedAgeSexSpayed/
Neutered?		Dominant?Other Information?
Do you have cats?Yes No
What other animals?
Veterinarian Reference
Please give your current or most recent veterinarian's information below (if none, leave blank):
Clinic:
Doctor:
Address:
City/State/Zip:
Phone: xxx-xxx-xxxx
About Your New Dog
How many hours at a time will
your dog be alone during the day?
Where will the dog be when alone?
Where will the dog be at night?
What type of excercise do you plan
for your new dog?
Where will the dog be
when you are out of town?
Are you willing to crate train your dog?Yes No
Are you willing to take your dog
through a recommended obedience course?		Yes No
Are you willing to have a home visit
by an Adopt A Lab volunteer?		Yes No
My ideal dog would be:
Other Information