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Adoption Questionnaire
First Name
*
Last Name
*
Address
*
City
*
State
*
Select State
Alaska
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Delaware
Florida
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Maine
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South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Guam
Puerto Rico
Virgin Islands
Zip Code
*
Email
*
Home Phone
*
Cell Phone
Work Phone
Employer
*
Name of Dog(s) of Interest
What role would you like your new collie to play in your life?
*
Companion for Self
Companion for Child
Companion For Pet
Obedience / Agility / Herding
Therapy
Farm Dog
Other
Residence Type
*
Please Select
House
Townhouse
Condominium
Apartment
Residence Type
*
Own
Rent
Your Yard
*
Please Select
No Yard
Fenced
Not Fenced
Electric Fence
Landlord's Name/Phone
Family Member Details
Self
Name
Age
*
Family Member 2
Name
Age
Relationship to Applicant
Select
Spouse
Child
Other
Family Member 3
Name
Age
Relationship to Applicant
Select
Spouse
Child
Other
Family Member 4
Name
Age
Relationship to Applicant
Select
Spouse
Child
Other
Family Member 5
Name
Age
Relationship to Applicant
Select
Spouse
Child
Other
Family Member 6
Name
Age
Relationship to Applicant
Select
Spouse
Child
Other
Family Member 7
Name
Age
Relationship to Applicant
Select
Spouse
Child
Other
Family Member 8
Name
Age
Relationship to Applicant
Select
Spouse
Child
Other
Your Daily Schedule
*
Do You Prefer a...
Please Select
Male
Female
No Preference
Traits you prefer
Behaviors That Will Concern You
Animals Living in Your Home
"
Pet 1
Name
Breed
Age
Gender
Pet 2
Name
Breed
Age
Gender
Pet 3
Name
Breed
Age
Gender
Pet 4
Name
Breed
Age
Gender
Pet 5
Name
Breed
Age
Gender
Pet 6
Name
Breed
Age
Gender
Have You Had Pets Before?
Veterinarian Name/Phone
*
Personal References
Please list two references that we may contact about your animal care experience and dedication.
Reference #1
*
Reference #2
*
Additional Information:
How did you find out about us?
*
*
I certify:
I have read the
Adoption Guidelines
.
The information that I provided in this questionnaire is correct to the best of my knowledge.
All members of my household have never been charged with cruelty to animals.
Please leave this field empty: