NEW BEGINNINGS
Rescue - Rehabilitate - Rehome - Resources
First Name:
Last Name:
Home Phone:
Cell Phone:
Work Phone:
Email:
Address 1:
Address 2:
City:
State:
Zip/Postal Code:
Home Ownership:
Own
Rent
Home Environment
Urban
Rural
Suburban
Occupation
Please list all household members, including live-in help and their approximate ages.(Also include frequent visitors):
Would you prefer Male / Female
Male
Female
Age of dog you would prefer:
Who will be assuming responsibility for this dog?
What type of fence is round the yard? Height and approx. area:
Does your front/back door open directly to the fenced yard?
Yes
No
Tell us about your current pets:
Breed, age, sex, neutered/spayed:
How and when did you lose your last dog?
If you ever lost a dog other than through death, how did it happen?
Have you ever given up a dog?
Yes
No
If yes, please explain:
You would give up a dog if______
When will you be ready for your new dog?
Where will your dog stay when no one is home?
For how many hours per day?
Where will your dog sleep?
Have run of the house?
Yes
No
Or be restricted to:
Use dog crate in what room?
Will be boarded for extended absences at:
Has your dog ownership ever caused you to appear in court? Please explain
Please check activities which will be shared with your new dog:
Walking
Obedience
Classes
Camping
Playing fetch
Swimming
Other
Veterinarians Name:
Phone:
Address:
City/State/Zip:
Groomer:
Phone:
Address:
City/State/Zip
Personal Reference
Phone:
Address:
City/State/Zip:
Comments or Special Notes:
Checking this box verifies that information submitted in this form is true
Verify
