First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone*

Alt Email

Text/Pager Email

Please list all occupants in your household including names and age.*

Who in the household will care for the pet*

Please list other pets, including names, species, gender and whether or not they have been spayed or neutered.*

List three references (include one family member and groomer if applicable) including phone numbers and email address.*

Please provide your most recent or current Veterinarian's Name and Phone Number Please notify your vet that we will be calling and authorize the release of information. If you are a first time pet owner, please call your local veterinarians and ask if they are accepting new patients. List the vet you plan on using for your new pet.*

Why are you interested in adopting a pet at this time*

Which animal are you interested in
Choose an animal: Romeo Walker

The pup you are applying for may have another application in process. If you would consider another pup, please select traits below so that we may make a recommendation.
Choose all that apply: Male Female Baby Young Adult Companion Protective Companion for Another Pet

Are you willing and able to take the pup to the vet for annual exams, vaccines and heartworm prevention.*
Choose one: Yes No

What brand of heartworm preventative medication do you use or intend on using?*

What kind of Flea and Tick control do you use or intend on using?*

If you are applying for a dachshund would you be able to afford back surgery, if needed, which can run up into the thousands of dollars? If not what would you do? Please think about this carefully. Dachshunds can have back injuries which may make them incontinent and/or unable to walk. This risk is increased when the dog is allowed to jump on and off furniture and become overweight and may happen at any age.
Choose one: Yes No

How much time will the pup spend alone during the day*

Where will the pup be kept when you are home*

Where will the pup sleep*

Where will the animal be kept when you are not home*

What if anything would cause you to surrender your pup? Please be aware that if you are no longer able to care for or want your adopted pup that he/she must come back to us.* *

Have you ever surrendered a pet? If yes, please explain*

How did you hear about us?*

Do you own or rent your home*
Choose one: Rent Own

If you rent, have you received the approval of your landlord to have an animal
Choose one: Yes No

If you rent, please enter your landlord's name and phone number

In what type of home do you live*
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

Does your yard offer a secure fenced in area?*
Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

What is the height of the fence

What type of fence
Choose one: Privacy Chain Link Invisible