*Denotes Required fields
Name of puppy you are interested in:*
Applicant(s) Full Name*
Your Address*
Address Line 2
City*
State* OhioAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington, D.C.West VirginiaWisconsinWyoming
Zip Code*
Cell Phone* example: 216-000-1111
Work Phone* example: 216-000-1111
Email*
Select: Married/Single/Partner?* —Please choose an option—MarriedSinglePartner
Do you own or rent your home?* —Please choose an option—OwnRent
How many children are in the family household? —Please choose an option—01234567891011121314>15
What are the ages of the children?
Have you ever owned a dog? YesNo
How many dogs do you currently own? —Please choose an option—012345678910111213141516171819>20
What type of breed are the dogs?
How old are the dogs?
Where do the dogs sleep?
If you have a primary veterinarian for your dog(s) please provide their name?
Please provide the veterinarian's phone number?
What brand of heartworm prevention do you provide your dog(s)?
What brand of dog food do you feed your dog(s)?
How many hours a day will the puppy be home alone?*
Are you familiar with the breed you are applying for?* —Please choose an option—yesnosomewhat
In a short description, please explain your level of familiarity with this breed? Character limit: 350/350
Have you physically visited any other shelters or rescues in the last 6 months?* —Please choose an option—YesNo
Place of employment*
How long have YOU been employed at this company?*
Your Spouse's/Partner's place of employment
How long has YOUR SPOUSE'S/PARTNER been employed at this company?
How did you hear about "Heaven to Earth Rescue?"* —Please choose an option—adoptapet.comFacebookGoogle Local ListingGoogle SearchMagazinepetfinder.comPetSmart LinkReferred by a friendReferred by a family memberTV AdYahooOther
In a 100 words (or more) please tell us why you are interested in adopting this puppy?* Character limit: 1850/1850
Please leave this field empty.
