Street address

City State Zip

Home phone Cell phone Work phone

Email address Would you like to be on our mailing list Yes No

What type of dog are you looking for? Breed?

Size? Age preference? Gender?

How many dogs do you now have?

Who will be the primary caretaker for this pet?

Please describe the household

List all children's ages

If there are no children currently in the household, do other children visit often? Yes No

Do you own or rent your home? Own Rent

Is it a house or apartment? House Apartment

Country or city setting? Country City

If you rent, please provide the name and phone number of your landlord

Please describe the dog's living situation
Inside Garage Basement Outside Pen Tied Guard Dog
Family Pet Business Residence Other

How many hours a day will the dog be left alone?

Will the dog be kept
In a crate Loose Tethered Inside Outside

Do you have any other pets at home? Yes No

If yes, please describe

Are they spayed or neutered? Yes No

Are they current on their vaccinations? Yes No

Please provide the name and phone number of your Veterinarian

How long did your last pet(s) live ?

Have you taken obedience training classes or are you self taught? Taken Classes Self Taught

Are you aware that a dog can live up to 15 years or more with good nutrition and medical care? Yes No

Are you willing to make that commitment to a dog that you adopt from the Hi Tor Animal Care Center? Yes No

In order to prevent behavioral problems and reduce the number of unwanted animals, we require that all our animals are spayed and neutered. Do you agree with this medical procedure? Yes No

If not, what are your concerns ?

Please provide us with the names and phone numbers of two acquaintances as references

Signature of interested adopter