First Name: *

Last Name: *

Address: *

City: *

State: *

Zip Code: *

County: *

Home Phone: *

Cell Phone: *

Work Phone: *

Email Address: *

Occupation:

Do You Work? None Selected From Home Office On Road No

Spouse/Significant Other's Name:

Spouse/Significant Other's Job:

Spouse/Significant Other's Phone:

Spouse/Significant Other's Cell Phone:

Does he/she work? None Selected Yes No

How many adults in home?

Names/Ages of Adults:

How many children in home?

Names/ages of children:

Are there any special needs/disabilities/allergies?

Are you working with any other rescue groups? None Selected Yes No

If yes, who?

What best describes your home? None Selected Private Home Condo or Townhouse Apartment Co-op Trailer Other

Do you own or rent? None Selected Own Rent

How long at this address? (years/months)

If you rent, provide name and number of landlord:

Do you plan to move within the next year? None Selected Yes No

Does your home have a yard? None Selected Yes No

Is it securely fenced? None Selected Yes No

Fence height/type:

How do you plan to exercise your dog?

Do you have any other dogs? None Selected Yes No

Are they spayed/neutered? None Selected Yes No

Vaccination up to date? None Selected Yes No

Do you have any cats? None Selected Yes No

Other pets or livestock? None Selected Yes No

List name, breed, sex, and age of each of your current pets:

Are all dogs/cats on heartworm preventative? None Selected Yes No

How many dogs have you owned in the past five years?

What happened to your last dog?

If last dog was given away, explain to who and why:

Have you owned a Boxer before? None Selected Yes No

List activities you plan to include your dog:

Age preferred/oldest you would consider adopting:

Sex of dog you prefer: None Selected Male Female Either

Color Preference: None Selected Any Color Fawn Brindle White

Boxer you're interested in:

Would you consider other Boxers or a different sex from your selected preferences? None Selected Yes No

What are your particular preferences for a dog if any, such as: "doesn't get on furniture", "must like cats", "good with children", ect:

Would you consider adopting a special needs dog (i.e. a deaf dog, or a dog requiring daily medication)? None Selected Yes No

Who will be the dog's primary caregiver?

Where will the dog stay during the day?

How many hours (on average) will dog be alone?

What will you do if your dog is destructive while alone?

List unacceptable behavior issues:

How would you discipline your dog?

Where will your dog sleep? None Selected Crate Family member's bed Garage Fenced yard Kennel Dog bed Basement Porch Outside shelter Dog house

Would you attend obedience classes with your dog? None Selected Yes No

What kind of food do you plan to feed your dog?

What would you estimate to be a realistic cost to properly care for your dog for a year?

Provide veterinarian's name and telephone number for each of your current and prior pets:

Please provide three personal references, not related to you (Name, phone + area code, and relationship):

Your comments: