I am willing to consider other dogs who meet my requirements / Yes / No
Name(s):
Address 1
Address 2
City / Postal Code:
Phone Number (include area code)
Tell us about you and your family: ages, work and school schedules
Is everyone in your household in agreement with this adoption? / Yes / No
If no, explain:
Who will be the primary care-giver?
What type of dog would best fit into your family? Explain any allergies.
I currently live in: / House / Apartment / Duplex
Mobile Home / Condo / Townhouse
Do you rent or own? / Rent / Own
If you rent your residence? / Are you allowed to own a pet(s)? / Have you met the requirements of your lease to have a dog?
Yes / No / Yes / No
Landlord’s Name:
Landlord’s Phone Number
Is your yard completely fenced in? / Yes / No / How high is your fence?
Tell us about your other animals
Are they spayed and neutered? / Yes / No
Where will the dog be when you are home?
Please go on to page two...
During that time, where will the dog be?
Will the dog be spending time in a dog crate on a daily basis? / Yes / No
If so, please provide the reason:
Are you prepared to take your dog to a veterinarian for regular check-ups and
vaccinations as required? / Yes / No
What will you do if the dog requires more extensive and possibly expensive medical treatment in the future?
Are you willing to bath or groom a dog on a regular basis? / Yes / No
Most Mosaic Rescue dogs will need obedience training. Are
you willing to go through the training process? / Yes / No
What type of food will you feed your dog?
If the dog requires a particular food preference, will you / Yes / No
supply it?
How will you discipline your dog for:
Please explain / Digging
Barking
Chewing
How and where (be specific) will you exercise your dog?
Why do you think you will be a good home for this dog?
References: Please provide the following for two people who can verify that you are a responsible dog owner (veterinarian, neighbours, etc.) / Name #1
Contact Info #1
Name #2
Contact Info #2