Name:__________________________________________________________________

Address:_________________________________________________ City:_____________ State:__________ Zip:___________

Phone:_________________________________________ Alt. Phone:_________________________________________

Email Address:_________________________________________

1. Where do you live? (Single family home, apartment, etc.) _____________________________________________

2. Do you own or rent? __________ How long at this address? __________

3. If renting, what is the Landlord's name and phone number? _________________

4. Is there a fenced yard? _________ Height:__________ Privacy or chain link? ______________________

5. Number of adults in household? __________ Number of children? __________ Children's ages? _________________

6. Have you ever owned a dog before? _____________ If yes, where is the dog now? ____________________

7. Have you ever turned a dog into a shelter? _________ If yes, what were the circumstances? ____________________________________________________________________________________________

8. How long will the dog be alone during the day?_______ Where will the dog be kept when alone?_______________

9. What other pets are in the household?__________________________________________________________

10. Are current animals spayed and/or neutered? ___________________________________

11. What is the name and phone number of your current veterinarian?_____________________________________________
___________________________

12. Where will this dog sleep?_______________________________________________________

13. When the pet is outside, what shelter is provided?_______________________________________________

14. Are you willing to provide heartworm prevention, flea and tick control for this dog along with any other necessary
medical expenses?_________________________________

15. Why do you want to adopt / foster a Dalmatian?____________________________________________________________________________________