Names of prospective owners:
Children? N/Y: if yes, names and ages:
Current Address:
City :
State:
Zip:
Phone Numbers: Home:
Work:
Fax:
E-mail address:
List all pets with names & ages:
Do you keep animals on your property like livestock, poultry, rabbits? ( ) yes ( ) no. If yes, explain what kind:
Do you ( ) rent ( ) own or ( ) other? If other, explain:
If you rent, do you have written permission from your landlord to have a dog? ( ) yes ( ) no
Do you have a fenced yard? ( ) yes ( ) no. If no, how will the dog be restrained when outside:
If a Chinook dog was place in your home:
who would be primarily responsible for the care of the dog:
where would the dog stay when the humans were at work or away from home:
where would the dog sleep at night:
would you be willing to take a dog to obedience class if necessary: ( ) yes ( ) no
Have you ever trained an adult dog or puppy? ( ) yes ( ) no. If yes, what types of training methods have you used?
Can you afford to provide the dog with food, shelter, and veterinarian care? ( ) yes ( ) no
Why are you interested in providing a home to a rescued Chinook dog?
What types of activities will you do with your dog? (i.e. walk, jog, hike, ski, sled)
Do you have any preferences or restrictions on the type of dog placed in your home? (For instance, specify desired sex of dog, age, etc. Can you provide a home for a special needs dog? Does the dog need to be house-trained?)
What other information should we know about you?
I/We can provide a ( ) temporary placement and/or a ( ) permanent placement for a Chinook dog.
Signature:
Date: