Date *

MM

DD

YYYY

Applicant Name *

First Name

Last Name

Home or Cell Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Phone Number

(###)

###

####

Co-Applicant (if applicable)

First Name

Last Name

Co-Applicant Phone Number

(###)

###

####

Co-Applicant Work Phone Number

(###)

###

####

Rent or Own? *

Rent

Own

Do you have a secure fence? *

No

Yes - Chain Link, Metal, or Wood 4ft

Yes - Privacy Fence - 6ft

Yes - Invisible Fence

Are all pets spayed and up to date on vaccines? *

Yes

No

N/A

Do you agree to provide regular health care by a Licensed Veterinarian? *

Yes

No

Do you agree to keep the dog as an indoor dog? *

Yes

No

Do you agree to contact Helping PAWS, Inc. if you can no longer keep this dog? *

Yes

No

Have you had dogs before? *

Yes

No

Provide a reference that is NOT family member *

First Name

Last Name

Reference Phone Number *

(###)

###

####

Provide a second reference that is NOT family member *

First Name

Last Name

2nd Reference Person's Number *

(###)

###

####