First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
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Email*

Home Phone

Work Phone
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Cell Phone

Alt Email

Text/Pager Email

How did you hear about us*

Why are you interested in adopting a dachshund at this time*

Have you applied with any other rescue*
Choose one: No Yes

What pets have you owned in the past*

Have you ever given up a pet? If yes, please explain*

Please list the breed/gender/age/name of all current pets in the home.*

Are all current pets spayed/neutered*
Choose one: Yes No N/A

Are all pets in your home current on their vaccinations*
Choose one: Yes No N/A

Are your dogs on Heartworm preventative*
Choose one: Yes No N/A

What brand Heartworm preventative do you use

Have you ever owned a dachshund before*
Choose one: No Yes

Which animal are you interested in
Sorry, no animals found

Would you consider a special needs dog or older dog

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

If you rent, have you received the approval of your landlord to have an animal*
Choose one: Yes No N/A

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

In what type of home do you live*
Choose one: Single Family Duplex Apartment Condominium Mobile Home

Is your yard fenced*
Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

What type of fence*
Choose one: Chain Link Wood Wrought Iron N/A

What is the height of the fence*

List the names and ages of all residents in the home*

Who in the household will care for the pet*

Has the decision to adopt a pet been agreed upon by all adults residing at this address*

Are you willing to take your dog to a veterinarian at least once a year for routine physical exams, vaccines and heartworm test*

Are you willing to be financially responsible for all routine, unexpected and emergency medical care for your rescue dog*

Where will the animal sleep*

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

How many hours will the animal spend alone during the day / night*

Who will care for your pet when you go out of town*

How would you describe the activity level in your home*
Choose one: Low Medium High

Veterinarian's Name and Phone Number*

Your place of Employment*

Your occupation*

Your spouse / partner's place of employment*

Your spouse / partner's occupation*

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