*Name:	Date:
*Address:
*City:	*State:   Minnesota Nebraska South Dakota   *Zip:
*Day Phone:	Evening Phone:
*Email:
*Dog Name:

Veterinarian's Name:		Clinic's Name:	Phone#:
Street Address:		City:	State:  Zip:
Your Family and Home
Do you live in a:     House   Apartment   Duplex   Townhouse/condo   Mobile
Do you own or rent:     Own   Rent         Name and phone of landlord:   Phone No.
Number of adults in household:    Number of children:    Ages:
Is anyone in your family allergic to dogs:     Yes   No  If yes, please explain:

Do you have a fenced yard?  Yes   No   Not Yet

If yes, what type of fence?  -Select- Chain Link Privacy Other   How high? -Select- 4ft 6ft 8ft 10ft Other  Is it fenced on all sides and secure? -Select- Yes No Not Yet ***Please Be Aware That Electronic (Invisible) Fencing Is Never Approved***

If no, how will the dog be contained when outside?

Will the dog ever be left outside alone? Yes   No    If yes, for how long?

Ownership Responsibilities - Please be as brief as possible.

Have you ever had a pet before? Yes   No
What pets are currently in your household?
TYPE	NAME	SPAYED NEUTERED?	KEPT WHERE?	BREED	AGE	YEARS HAD?
DogCat		YesNo	InOut
DogCat		YesNo	InOut
DogCat		YesNo	InOut
DogCat		YesNo	InOut
List your previous pets and describe why you no longer have them.
TYPE	NAME	TYPE/BREED	DATES LIVED WITH YOU
DogCat
Explanation:
DogCat
Explanation:
DogCat
Explanation:
DogCat
Explanation:

How long have you been looking to add a dog to your family?:

What is the primary reason you are getting a dog at this time?

Where will the dog be allowed in your home?

Where will the dog sleep at night?

Where will the dog be kept when you are not home?

Average number of hours the dog will be left alone each day:

Please describe what your daily routine with the dog may be:

Are you familiar with crate training and its use? Please describe:

Are you willing to assume ALL veterinary costs from the date of this adoption forward?:     Yes   No

I authorize the landlord, if any, and their agents to release to BWBR any information in my rental agreement that pertains to pet owning and keeping. I authorize the veterinarian listed above to release to BWBR any information pertinent to evaluating my history of pet ownership, if any. If for any reason you are unable to take care of this dog, it MUST be returned to Borders Without Boundaries Rescue. We reserve the right to determine whether or not it is in the best interest of the dog to be adopted by any individual, and, if not, to refuse the adoption.

*I Agree     Yes   No

Thank You for taking the time to complete this application. Be assured we will give this our highest priority.  You will be hearing from us soon!