Contact Information |
Yourself |
| First Name: |
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| Last Name: |
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| Street Address: |
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| ZIP: |
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| Occupation: |
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| 1st E-Mail Address: |
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| 2nd E-Mail Address: |
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| Home Phone: |
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| Work Phone: |
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| Cell Phone: |
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| Other Phone: |
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| Best Day/Time to Contact: |
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Emergency Contact |
| Name: |
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| Phone Number: |
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Personal Reference 1 |
| Name: |
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| Phone Number: |
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Personal Reference 2 |
| Name: |
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| Phone Number: |
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Personal Reference 3 |
| Name: |
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| Phone Number: |
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Personal Reference 4 |
| Name: |
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| Phone Number: |
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Your Veterinarian
(By submitting this form, you provide your consent for your veterinarian to release information regarding the health status of your current animals). |
| Name: |
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| Address: |
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| 2nd Vet Name: |
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| Address: |
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| Phone: |
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Your Landlord |
| Do you own your home? : |
Yes No |
| If you do not own your home, please provide a letter of permission from your landlord for you to have a Dalmatian and provide your landlord's: |
| Name: |
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| Address: |
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| Phone: |
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General Questions: |
| How did you hear about us? : |
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| Why do you want to adopt a Dalmatian? : |
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| Have you had a Dalmatian before? : |
Yes No |
| What do you know about Dals and where did you get this knowledge?: |
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| Do you consider yourself/your family to be active in such a way as to include your Dalmatian? Describe: |
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Your Home, Family, & Pets |
| What dogs do you currently have (Breed, Age, Sex)? : |
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| What other pets do you currently have (Breed, Age, Sex)? : |
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| What pets have you had in the last 5 years that you no longer have? What happened to them? : |
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| How do your dogs get along with other dogs? : |
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| What dog food do you feed? : |
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| Is/are your dogs altered? : |
Yes No |
| Ever breed a litter? : |
Yes No |
| Willing to train in obedience? : |
Yes No |
| Anyone home during the day? : |
Yes No |
| Hours a day the dog would be left alone : |
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| Where will dog stay when you are home? : |
Inside Outside |
| When the dog is alone, where will it be (Check all that will apply regularly) ? : |
Run of the House Crated
Outside Garage
Other (Please Describe) |
| Is yard completely fenced and fence secure? : |
Yes No |
| What type of fencing and height? : |
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| Is there a door leading directly from the house into the fenced yard? : |
Yes No |
| What kind of shade is available in the fenced yard? : |
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| What kind of accomodations do you have for the dog in the cold? : |
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| Do you have a dog door into the house or garage? : |
Yes No |
| Do you own/have you used a dog crate? : |
Yes No |
| What do you do with your pets when you go on vacation? : |
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| Ages of children in contact with the dog? : |
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| Any asthma or allergies to dogs or cats in your household? : |
Yes No |
| Are your animals current on vaccinations? : |
Yes No |
| Are your animals on heartworm preventative? : |
Yes No |
| Describe neighbors the dog will be involved with (Do they like dogs? Have children (Ages?) Have dogs or cats?) : |
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| Any current neighbor problems? : |
Yes No |
| If yes, Explain : |
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| Any preferences regarding the Dalmatian you are looking for (Age/Sex/Color)? Specify : |
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| Do all parties (If more than one adult in house) want a Dalmatian? : |
Yes No |
| Any questions about the breed we can answer? |
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| Adopted pets need an adjustment time. Are you willing to give the new dog at least one month trial to ensure proper adjustment? : |
Yes No |
| What would, in your opinon, constitute a reason for not keeping the dog? : |
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| Would you consider a second Dalmatian at a future date? : |
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| We are always in need of temporary homes for our rescue dogs. Would you be willing to foster a needy Dalmatian if it is compatible with your lifestyle and other pets? : |
Yes No |
| For how long? Until placed? : |
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