Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Are you a past or present:

Veteran

Firefighter

Law Enforcement Officer

Dispatcher

EMS

Gold Star Family

Family of a First Responder Lost in the Line of Duty

Has anyone currently living at the residence ever been convicted of a felony *

Yes

No

Do you often have elderly visitors? *

Yes

No

Do you often have infant/toddler visitors? *

Yes

Yes

Do you often have visitors under 16 years old? *

Yes

No

How would you describe your family's activity level? *

Quiet/sedentary

Moderate activity

Athletic/very active

Do you own or rent your current residence? *

Own

Rent

Type of current residence: *

House

Apartment

Condo

Townhome

Other

Do you have a fenced yard? *

Yes

No

Veterinary Clinic Phone Number *

(###)

###

####

Can we contact this veterinary clinic? *

Yes

No

Are you interested in a specific dog? *

Yes

No

If your preferred dog is unavailable, are you willing to consider a different dog? *

Yes

No

Please select all potential excessive personality/health/behavior issues that are undesirable or incompatible with your preferences: *

Barking

High energy

Low energy

Fearful

Training required

No cats

Special diet required

Mild health concern

Moderate/severe health concern

Shy/timid

Wallflower

Social butterfly

Reactive (dogs)

No other dogs

No small animals

High prey drive

Shedding

Long-term medication

No Kids

Reactive (people)

None

Other

Personal Reference Name *

Cannot live in your household

First Name

Last Name

Personal Reference Phone *

(###)

###

####

Personal Reference Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country