Name: 
  Address: 
  City:     State:  ALAKAZARCACOCTDEDCFLGAIDILINIAKSKYLAMEMDMAMIMNMOMSMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
  Postal Code: 
  Country: 
  Daytime Phone:   
  Evening Phone:   
  Cell Phone:      
  Email:           

  Best time to reach you  MorningAfternoonEvening
      

  Description of current residence:  ApartmentCondominiumTownhomeTrailerSingle Family Residence
  How long have you lived at your present address?  years.
  Select one?  Own  or Rent 
  
  If renting, please provide landlord's contact information.
  Landlord Name:    
  Landlord Address: 
  Landlord City:     Landlord State:  ALAKAZARCACOCTDEDCFLGAIDILINIAKSKYLAMEMDMAMIMNMOMSMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
  Landlord Postal Code: 
  Landlord Daytime Phone:   
  Landlord Evening Phone:   
  Landlord Email:            
  Occupation of household members:    
  Employer(s):  
  Please list names and ages of all people who will be 
  living with the dog:
  
        

  How did you hear about FSSR?
  Why would you like to adopt a dog?
  
  Will this be your first dog?Yes  No

  If no, list breed(s): 
  Please List Breeds Here 
      

  List other pets you currently own:
  (Please indicate breed, age, temperment, sex and whether they are 
  spayed/neutered.)
  
      

  Have your current dogs been tested for heartworm?
  Yes  No 

  Are your current dogs on a heartworm preventative?
  Yes  No

  Please list any characteristics your current pets have that
  FSSR should be aware of:
  Please list characteristics of your current pets.
      

  Current Vet:
  Name:    
  Address: 
  City:     State:  ALAKAZARCACOCTDEDCFLIDILINIAKSKYLAMEMDMAMIMNMOMSMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVAVTWAWIWVWY
  Postal Code: 
  Phone:   
      

  Is someone home during the day?
  Yes  No

  Work hours?  
      

  Where will the dog be kept during the day?
  
  Where will the dog be kept during the night?
  
      

  Who will be the primary caretaker of this dog?
  
      

  Do you have a fenced in yard? Yes  No
  Type of Fence: 
  Height of Fence: 
      

  Please describe your exercise plan for your dog:
  
      

  Are you aware the yearly maintenance of a dog is approximately $200
  (not including food or grooming)  Yes  No

  Please describe plans for care of your dog while away (i.e. vacation):
  
      

  Are you willing to obtain a crate and crate-train your dog,
  if necessary?  Yes  No  
  If no, why?  
      

  Are you willing to take your dog to a basic obedience course,
  if necessary?  Yes  No
  If no, why?  
      

  Do you have the time to house train a dog, if necessary? 
 
    Yes  No
 
  Describe your house-training method:
  
      

  What would you do if your dog bit someone?
  
  
  Have you ever had to put an animal to sleep?
    Yes No

  If yes, why did you have to?
  
  
  For what reasons would you give up an animal to a shelter or rescue?
  
  
  Have you or any household member ever been arrested or convicted 
  of animal abuse or neglect?
                Yes No
 
  Are you willing to have a FSSR representative visit your home by 
  appointment?Yes  No
      

  Canine preference (rescued canines typically range in age from 
  1 year to 8 years old - on rare occasions we do rescue litters of puppies):
  Color:    Sex:  ChooseNo preferenceMaleFemale  Age:  
        

    References:

  Please provide the names, addresses, and phone numbers for two
  people who are not relatives and do not reside in your household.

  PLEASE NOTIFY YOUR REFERENCES AFTER SUBMITTING THIS FORM
  THAT WE WILL BE CONTACTING THEM

  Reference #1:
      

  Reference #2:
      

  Please check to make sure you have completed all of the above
  sections, and feel free to use the comments box below to provide
  any further information you feel will help us in evaluating 
  your application.

  Comments: