Name*

Street*

City*

State*

Zip*

Phone*

Email*

Date of birth*

Collie's name

List dogs you own or have owned in the last 3 years

Breed(s)

Spayed/Neutered?

What has happened to him/her?

List cats

Do you have children? If so, what are their ages?

Vet name and phone

Do you have a fenced yard?
YesNo

If yes, describe the fence

Are your current pets on heartworm preventive, and the brand of medication?

Are you familiar with local animal ordinances?
YesNo

Does any member of your household have allergies?
YesNo

Do you plan to chain or tie your Collie outside at anytime?
YesNo

Are you employed?
YesNo

Are you or your spouse currently serving in the military?
YesNo

May I come to your home and visit this pet?
YesNo

Has your pet ever been taken to Animal Control?
YesNo

If yes, why, and did you redeem it?

Why do you want this collie?

Will your Collie be kept:
IndoorsOutdoorsBoth

Who will be responsible for this Collie?

What will you do with this Collie if it is not working out?

Do you Own/Rent If renting, provide name and phone # of landlord

Type of housing:
HouseApartmentMobile HomeCondo

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