| Full Name: | |
| E-mail Address: | |
| Phone Number: | |
| Home Address: | |
| City: | |
| State: | |
| Zip Code: | |
| Date of Birth: | |
| Occupation: | |
| Work Phone: | |
| Employer: | |
| Marital Status: | |
| Do you have any Children?: | |
| If you have children, how many and what ages are they?: | |
| Are there any other individuals living in the same household? Names and ages: | |
| Does anyone have allergies or asthma that would be aggravated by a pet?: | |
| Have you ever owned a pet before? What kind?: | |
| What happened to your previous pet(s): | |
| Are there any other pets? Type, Breed, Age, Gender: | |
| Are any of your pets spayed/neutered?: | |
| Are any of your pets current on their vaccinations?: | |
| Name and phone number of your past or present veterinarian: | |
| Do you rent or own? If renting, name and number of your landlord: | |
| Have you discussed adopting a pet with your landlord and been approved to have a pet?: | |
| Where will the dog(s) stay during the day and at night?: | |
| Have you discussed adopting a pet with your family? Is everyone in agreement about adopting?: | |
| Are you out of town a lot or travel much? If so, what do you plan on doing with the animal while you are gone?: | |
| Will the dog(s) be with someone durring the day?: | |
| Do you have a fenced in back yard? If so, what kind(material) of fence is it? How high is it?: | |
| Would you take your dog through a basic obedience course if needed?: If not why? | |
| Have you ever been convicted of animal abuse or animal cruelty? Have you ever been in jail? If so, please explain: | |
| Would you be OK with LBL Animal Rescue doing a background check to make sure that all of the information listed above is correct?: | |
| Name of dog(s) you are interested in: | |
| Signature: | |
| Date: | |
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