Fields  marked with a * Must Be Answered
Also, some fields  are noted as follows (This is a required question, please answer)
answer these fields specifically as possible.
Failure to fill in these fields will cause your application to be rejected.

*First and Last Name

*Address

*City:                                       *State:                          *Zip:     

*Home Phone:                               Work Phone:                         *Evening Phone:

Email Address:       

Best time to contact you: 

*Ages of Adults in your home - check all that apply:
            18 - 25 ______
            26 - 35 ______
            36 - 45 ______
            46 - 55 ______
            56 - 66 ______
            67 - 77 ______
            78 - 88 ______
            89+     ______  

*What kind of dog are you looking for  

*What activity level in a dog are you looking for? Very active, moderately active, low level of activity: 
(This is a required question, please answer)

*Have you had dogs before?                          What kind(s)

*What happened to your dog(s)?

*Will your dog primarily be an indoor or outdoor dog?
(This is a required question, please answer)

*Do you have a doggy door?                                      If not, would you install one? 
(This is a required question, please answer)

*Type of residence: House              Apartment                    Other e.g.: Condo/Townhouse (please explain)

___________________________________________________________________________________________________

*Do you own or rent your home?

*Do you have a fenced yard?                 If yes, Type of Fence e.g.: Wood, Block, Chain link,

Other: ___________________________________________________________________________________________________________
(This is a required question, please answer and please be specific about fence type)

*Do you have a pool?                If so, is it fenced?

*Number of adults in your household:

*Have you discussed this adoption with all household members?

*How do the other household members feel about adopting a dog?

_____________________________________________________________________________________________________

*Ages of children in your household (including children who are visitors):

*Please list any other pets or animals in your home:

*Do you have a regular Veterinarian? If so, please give his/her name and phone number:

*Do you have a regular Groomer? If so, please give his/her name and phone number:

*How many hours per day will your dog be left alone?

*When you travel or go on vacation, what will you do with your dog?

_____________________________________________________________________________________________________

*A dog can live for 15 or more years. Are you ready to make that kind of commitment?

_____________________________________________________________________________________________________

Please Email:contactsmalldogresucenow@tikiblackdog.org  your application to me. Please scan for viruses First!!