Golden Retriever preferred:  Sex Male Female Either   Age 1-3 4-6 >7 Any years old

Applicant Name:  Age:

                        (Must be at least 18 years old)

Co-Applicant Name:   Age:

Relationship to Applicant: Spouse Parent Guardian Child Roommate Other If other: (please specify)

Street Address:

City:    State:    Zip Code:

Mailing Address (if different than above):

Home Phone:   Cell Phone: Best Time to Call:

E-Mail Address:

Applicant's Employer:

Position:   Phone:

Co-Applicant's Employer:

Position:   Phone:

Questions:

1. Do you live in a: Apartment Condominium Duplex House Townhouse Other

2. Do you have a fenced yard? Yes No   If yes, what type of fence?  

                                                            And what is its height at its lowest point? Less than 3 feet 3 to 4 feet 4 to 5 feet 5 to 6 feet More than 6 feet

3. Where will this pet be kept during the day?  

                                                    At night?

4. How many adults live in your household? 1 2 3 4 More than 4   Children? None 1 2 3 4 5 6 More than 6  

    What are the children's' ages? (Use the CTRL key for more than one selection)

             0-3 Yrs old 4-6 Yrs old 7-9 Yrs old 10-12 Yrs old 13-15 Yrs old 16-18 Yrs old

5. Is anyone at home during the day? Yes No   Who? Applicant CoApplicant Other Adult in the Home

6. Who will be responsible for caring for this animal? Applicant CoApplicant Other Adult in the Home

7. How many hours will this pet be alone per day? Less than 1 1-4 4-8 More than 8

8. Please list all the pets you have owned in the past three years:

    Type                 Sex     Age         Spayed/Neutered?                     Where is it Now?

9. If you have ever had a pet die at an early age, or due to an accident, please explain the circumstances:

10. If you do not have adequate fencing (i.e. a totally enclosed, secure yard) how will you exercise the foster dog?

Who will supervise these outdoor activities?  (This includes ALL times that the dog is outdoors.) Applicant CoApplicant Other Adult in the Home

11. Have you ever been convicted of a felony or animal abuse? No Yes

12. How did you hear about GRREAT? Animal Clinic Friend/Family Golden Day Internet Search Magazine Newspaper Other Web Site

13.  Other comments or questions you may have:

I ACKNOWLEDGE THAT ALL THE INFORMATION CONTAINED IN THIS FORM IS TRUE AND CORRECT. 
I UNDERSTAND THAT ANY MISREPRESENTATIONS OF FACT MAY RESULT IN THE REMOVAL OF THE FOSTERED DOG FROM MY HOME BY SEVA GRREAT.

Yes No