Main Contact Information

• Cell Phone*
  
  example: 216-000-1111

• Work Phone*
  
  example: 216-000-1111

• Email*
  

Household

• 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

Employment

• 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?
  

General Question

• 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.