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Personal Information

First name*

Last name*

Email*

Email Confirmation*

Birthday

Month

Day

Year

Country/Region

Address

City

Zip / Postal code

Home Phone*

Cell*

Pet Information

Dog's Name

Dog's Breed

Example"Golden Retriever, Goden Doodle, Retriever/Lab mix

Dog's Gender

Male

Female

Dog's Age

Weight

Color

How did you get this dog?

Example: Breeder, Rescue, Craigslist, Stray/Found

Microchip Information

Is this dog microchipped?

Yes

No

I do not know

If Yes please provide the microchip number*

Dog Behavior

The dog likes:

Men

Women

Children under 10

Children over 10

Other dogs

Cats

Dog dislikes:

Men

Women

Children under 10

Children over 10

Other dogs

Cats

If the dog has dislikes please describe their reaction

Example: The dog lays on the ground an shakes

Has the dog ever bitten anyone?

Yes

No

If yes, please describe the situation in which the bite incident occurred. Has it happened more than one time? Where there any unusual circumstances that provoked the bite?

Enjoys (Check all that apply):

Swimming

Baths

Playing ball

Taking walks

Car Rides

Is the dog fearful of anything?

Example: Loud noises, Groomer

Knows how to (check all that apply):

Sit

Stay

Down

Good Recall

Crate Trained

Other

If other, please explain

Example: Has training to help children with special needs

P.O. BOX 513

Lecanto, FL 34460

joshuashousegrr@gmail.com

352-228-7573

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