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Chihuahua you are applying for

Name *

Address *

Email Address *

Home Phone *

Cell Phone

Work Phone

Are you over 21 yrs of age *

Select an option


Marital Status

Spouse's Name

Is Spouse over 21 yrs of age *

Select an option

Spouse's Occupation

How long have you lived at this address


Type of Residence


Do you have a fenced back yard

Select an option

Type of Fence

Condition of Fence

Select an option

If Renting, are dogs allowed

Select an option

Landlord's Name, Address, Phone

Name, Age, Relationship of any other adults living in the home

Name, Age, and Relationship of any children living in or frequently visiting the home

Are you planing on having any children in the future

Select an option

List the Name, Type or Breed, Gender of any dogs living in the home, and how long you have had them

List any other dogs owned within the last 10 yrs, and why you no longer have them (ie stolen, died, gave away, etc.)

Describe an average weekday in your home

What will your newly adopted pet's living situation be like when you are not home

How will you exercise your dog

What do you consider reasonable routine vet expenses per year

Primary Veterinarian, Address, Phone

Secondary Veterinarian, Address, Phone

Are your current pets on heartworm preventative

Select an option

Are your pets current on vaccines

Select an option

Are your pets spayed or neutered

Select an option

What temperament in an adopted dog will best suit your personality or lifestyle

List Name, Phone, and Relationship of Three Friends or Relatives

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