Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
List your employer, how long you've worked here and your work place phone number:
*
List your spouse or significant other's name and how long you all have been together:
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List your spouse or significant other's employer, how long they've worked there and their work place phone number:
*
Dog(s) - Type (select all that apply)
*
Description- Please list breed, color/pattern, size, hair type/length OR list the name(s) of the dog(s) you are applying for:
*
Household information - Please select your type of residence and indicate if you own or rent:
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How long have you lived at your current residence? If renting, list landlord's name, number and the name of complex (if applicable):
*
Household information- Adults (#), children (# and ages), dogs (#), cats (#), other pets (type and #)? Please list:
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Does everyone in the household want a dog?
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How long have you been wanting to get a dog?
*
Is anyone in the household allergic to dogs?
*
About how many hours per day is someone home?
*
Who will be the main caregiver?
*
What is your basic lifestyle? (Calm, noisy, busy, etc.):
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Where will the pet spend most of its time?
*
Has anyone in your household had any pets before? If so, what happened to them?:
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Do you have a fence? What type/height?
*
If you don't have a fence, do you have a dog pen or what are your plans for taking your dog outside?
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Can you afford proper care for a pet (good quality food, vaccinations, flea/tick preventive, de-worming, ect)?:
*
Veterinarian information - name, phone number and the person's name that is on the account. If you do not have a current vet but had one for past pets, please list their name, phone#, name of person on account and when last used.
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If no current veterinarian, who do you plan to use?
Reference 1 - name and phone number (references must not be related to you):
*
Reference 2 - name and phone number (references must not be related to you):
*
I CERTIFY that all information provided is accurate, UNDERSTAND that all applications will be processed for accuracy and references checked, UNDERSTAND that applications that are incomplete may be voided and not contacted, UNDERSTAND that HSCC has the right to deny any applicant for any reason.
*
