Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Current Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Spouse Name

First Name

Last Name

Personal Reference Name *

Must not be a family member.

First Name

Last Name

Reference's Phone Number *

(###)

###

####

Do you own your home? *

Yes

No

Are pets allowed in your home? *

Yes

No

Landlord's Name

(If applicable)

First Name

Last Name

Landlord's Phone Number

(If applicable)

(###)

###

####

Are any members of your household home during the day? *

Yes

No

Do you have other dogs? *

Yes

No

Are they all spayed/neutered?

Yes

No

Do you have any other animals/livestock? *

Yes

No

Who is your regular/most recent veterinarian?

First Name

Last Name

Veterinarian's Phone Number

(###)

###

####

Approximate date of last vet visit

MM

DD

YYYY

Is/Are your current dog/s up to date with heartworm testing and prevention? *

Yes

No

N/A

Are your animals current on vaccines? *

Yes

No

N/A

Have you owned boxers before? *

Yes

No

Are you willing to consider a boxer mix? *

Yes

No

Adoption fees are $350. Do you understand your fee will be due at the time of adoption? *

Yes

No

Do you agree obey all leash laws? *

Yes

No

Do you agree to provide regular health care for the dog(s)? *

Yes

No

Do you agree to return the dog to MTBR if you can't keep it? *

Yes

No

Would you agree to a house check prior to adoption? *

Yes

No

Have you or anyone in your immediate family been convicted of a charge of animal cruelty, or are charges pending? *

Yes

No

MTBR is committed to finding successful homes for the life of our dogs. Do you intend to commit for the life of the dog? *

Yes

No

By submitting this form, I swear that all information contained is true and complete. *

Yes

No