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Name (first, last) |
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E-mail |
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Street Address |
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Address (cont.) |
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City |
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State/Province |
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Zip/Postal Code |
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Occupation
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Day/Work Phone |
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Home Phone |
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Cell Phone |
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REFERENCES: |
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Please provide the contact information of a
veterinarian you have used before and plan to use with your new dog. Vet
references are checked. |
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Vet Name |
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Vet Phone |
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Vet records are under the name of: |
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Please indicate place of employment for yourself and your
spouse, if applicable. |
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SELF: |
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Name/Address of Employer |
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SPOUSE's name |
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Name/Address of Spouse's Employer |
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HOUSEHOLD INFORMATION |
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Residence |
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Home |
Own
Rent |
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Condo |
Own
Rent |
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Apartment |
Own
Rent |
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If you rent,
you must provide your landlord's contact information so that we may verify
that you are allowed a pet. |
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List below
all people who currently live at this residence: |
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Name |
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Relation to you |
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Age |
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Does anyone in your house have any known allergies to dogs? |
Yes
No |
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List any cats, dogs, etc. who currently live in your house |
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Name: Type Breed:
Age:
Sex/Neutered:
How long owned: Kept Where: |
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HISTORY |
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Have you owned a dog before? (If yes, please provide
us with a brief history of what happened to it. If your last dog died,
please state dog's name and date deceased. |
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Have you ever taken one of your dogs to a shelter? If
yes, please describe circumstances. |
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CARE OF THE DOG |
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Do you have a fenced area on our property? If
yes, how high is the fence and approximately how large is the fenced-in area? |
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If you have no fence, how do you plan to have your
new dog relieve itself? |
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Do all adults work full time |
Yes
No |
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How many hours each day will your new dog be alone? |
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How many hours each day will you spend time with your
dog? |
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Where will your new dog be kept when it is alone? |
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Where will your new dog sleep? |
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What type of training do you plan on providing the
dog? |
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DONATION |
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We request a donation of $250 to $350 , depending on
the expenses incurred in the dog's rescue and Veterinary Care. All our
Siberians are health checked, up to date on vaccinations, spayed/neutered,
micro-chipped, heartworm negative and on preventative. Is this acceptable?
YES
NO
Please realize that dogs need vet care throughout their lives,
including yearly boosters, heartworm and flea/tick preventative meds, etc.
If you cannot afford a donation, can you afford the appropriate vet care?
Please consider this before adopting.
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Are there terms acceptable to you?
YES
NO |
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Print Name |
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Date |
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