First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

Email*

Home Phone

Cell Phone

Alt Email

Is there a certain Dog you are interested in, if so, which one?
Choose an animal: Ace Bella Butterscotch Crosby Hanna B Harlow Jazzy Mickey Oscar Roxy Sinatra Sparky Tessa

Veterinarian's Name, Address and Phone Number*

Will the animal be kept inside or outside*
Choose one: Inside Only Outside Only Inside and Outside

Where will the animal be kept when you are not home*

Do you currently have any other pets?

If yes, please describe the pets in detail: Name, Age, How long in your home, Full description including sex *

If 'yes' are they currently on heartworm preventative?*
Choose one: Yes No

Do you own or rent your home?*
Choose one: Rent Own

If you rent, please enter your landlord's name and phone number*

Who will be responsible for the caring for your dog if something should happen to you?*

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.