First Name:*
Last Name:*
Street Address:
City:
State/Province Select:
  Select state/province from list
 
Postal Code:
Phone Number:
Phone Type:
Alternate Phone:
If you rent, please tell us your landlord's name and phone number:
How many children live in the home, and what are their ages?
How many hours each day will the adopted animal be without human companionship?
Otherwise, describe in detail the type of dog you're looking for::
If other, please explain why you want this dog:
If no, please explain why not:
If no, please explain in detail:
Please provide one reference that is NOT your vet or someone living in your home:
Please provide your veterinarian's information (after submitting this form please CALL your vet & give them your permission to speak to us)::
If yes, please explain further:
If yes, please explain the circumstances: