Have you ever been convicted of a felony?

YESNO

Interested In (dog’s name):

Today’s Date:

Personal Information

First name:

Last name:

Birth date:

Social Security Number:

Drivers License Number:

Email (required)

Street Address 1:

Address Line 2:

City:

State:

Zip:

Housing

Type of housing:

ApartmentCondoHouse

Can you provide a copy of lease (if applicable):

YESNO

Landlord’s name:

Landlord’s phone number:

Years at current address:

1234567891011121314151617181920

If under 2 years, previous address:

Home phone number:

Cell phone number:

Marital status:

SingleMarriedOther

How many adults in the house:

01234567

Name, age and relationship of other adults:

1.

2.

3.

4.

5.

How many children in the house:

012345678

Age of children:

Do you have a fenced yard or kennel run?

YESNO

If so describe:

Does anyone in the home have allergies:

YESNO

Do all the adults in the house want a pit bull?

YESNO

If not, who and why:

Are there other dogs in the house?

YESNO

If so please provide breed, sex, age and if they are spayed/neutered:

Any cats in the house:

YESNO

How many other animals have you had in the past 5 years:

Where are they now? Still alive, put to sleep, given away, lost, hit by a car:

Work

Employer address:

Employer phone number:

Years at employer:

12345678910more

Typical hours worked:

Care

How will you handle exercise and potty needs:

How many hours will the dog be left alone:

0123456789101112131415161718192020+

Who will be the primary caregiver of the dog:

Why do you want a pit bull:

Describe your lifestyle:

Where will the dog live primarily:

What activities will your dog participate in:

Will you crate your dog when needed?

YESNO

If no, why:

How will you handle mischievous behavior, digging, chewing, etc:

How will you handle any unwanted behavior:

What would cause you to return the dog:

Are you prepared for the personal attention this breed needs:

YESNO

Do you have the time and ability to train and exercise a strong, large dog

YESNO

Are you ready to commit the next 10-16 years to this dog:

YESNO

Current vet’s name:

Current vet’s address:

Current vet’s phone number:

References

Please provide 2 personal references (not relatives)

1.

Name:

Address:

Phone number:

Relationship:

2.

Name:

Address:

Phone number:

Relationship:

Please provide 2 family members who will know your whereabouts for the next 5 years:

1.

Name:

Address:

Phone number:

Relationship:

2.

Name:

Address:

Phone number:

Relationship:

THE INFORMATION ON THIS APPLICATION WILL BE KEPT CONFIDENTIAL.

BY SUBMITTING THIS APPLICATION, I CERTIFY THAT ALL INFORMATION PROVIDED IS COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT YOU MAY RUN A BACKGROUND CHECK AND WILL CHECK ALL MY REFERENCES.

AGREE and DIGITALLY SIGN.

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