Date:
Name: Phone:
Address:
Email:
Number of adults and ages of children in the home:
Occupation(s):
Is one adult at home during the day? Yes No
Details:
Is your property owned or rented? Owned Rented
Is your yard fenced and secure? Yes No
Are you prepared for the dog to live in the house as a member of the family? Yes No
Would you have any out of bound areas for the dog? Yes No
Are you prepared to transport the dog to and from the office daily? Yes No
Have you had any experience with dogs or training? Yes No
Are there any pets in your home? Yes No
Do you have any preference to the breed or sex of the dog? Yes No
When would you be able to take a dog? (if accepted):
Why is it you would like to become an adult dog raiser?
Relationship: Years Known:
Comments/Notes:
