Name *

First Name

Last Name

Phone *

(###)

###

####

Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does anyone in your home have allergies to animals? *

Yes

No

Have you adopted pets in the past? *

Yes

No

Are you aware of the financial obligations owning a pet involves? *

Yes

No

Will you provide your dog with routine veterinary care? *

Yes

No

Are you willing to potty train your dog? *

Yes

No

Do you have a history of animal abuse? *

Yes

No

If you must move from your current address, are you willing to guarantee you will bring your dog with you? *

Yes

No

Do you understand you are committing to care for your dog for the rest of his or her life? *

Yes

No

If for any reason you are unable to keep your dog, you will surrender him or her to Miles of Love *

Yes

No