Please be sure to include your E-mail address so that we can contact you.

* Today's Date (mm/dd/yyyy)

* Full Name

* Street Address

Address (cont.)

* City

* State (Ex: WA)

* Zip Code

Work Phone

* Home Phone

* E-mail

* Verify E-mail

* Are you interested in adopting:

Male Only
Female Only
Either Sex

* Would you consider adopting a Scottie Mix?

Yes
No

* Would you consider adopting an older Scottie (over 8 years old), a terminally ill dog, or a Scotty who has special needs (like blindness, deafness, a medical condition such as Cushings that may require daily attention)?

Yes
No

* Would you take two Scotties?

Yes
No

* Have you ever previously owned either a show or pet Scotty, or had a Rescue Scotty? Please explain below.

Yes
No

* Do you live in a:

House
Apartment
Condominium
Other (if other, please explain below)

* Do you Rent or Own?

Rent
Own

* Do you have a fenced yard?

Yes
No

* Do you have a pool or any other open body of water anywhere on your property?

Yes
No

* Please indicate the age of the primary caregiver.

Unspecified
Under 15
15-25
26-55
56-75
76 - older

* Will this dog come in frequent contact with children?

Yes
No

* Do you have minor children/grandchildren living at home or frequently visiting?

Yes (if yes, please answer the question below)
No

The age of your youngest child/grandchild is:

0-5 Years
6-10 Years
11-15 Years
16 and Over

* Number of Adults in Household (over 18)?

* Where will the dog stay during the DAY?

* Where will the dog stay at NIGHT?

* Typical Vacation Arrangements:

* Please list other pets you CURRENTLY own, their ages, and their sex:

* Your Veterinarian's Name & Phone Number (As a Reference):

* Personal References (please provide two, include their address, phone number and years you have known them):