DATE:_____________________

NAME:______________________________________  PHONE:________________________

ADDRESS:___________________________________________________________________

BREED:__________________ SEX: M/F  COLOR:__________ AGE:______ ALTERED: Y/N 

CHILDREN AT HOME? Y/N  AGES:_______________________________________________

DOGS NAME:_______________________ HOUSETRAINED: Y/N  DIGS: Y/N  BARKER: Y/N

BEHAVIOR WITH CHILDREN:____________________________________________________

BEHAVIOR WITH OTHER DOGS:__________________________________________________

BEHAVIOR WITH OTHER ANIMALS:_______________________________________________

DOG AGGRESSIVE: Y/N  FENCE CLIMBER/JUMPER: Y/N   SHOTS:____________________

REASON FOR PLACING IN NEW HOME:____________________________________________

___________________________________________________________________________

DATE DOG MUST BE OUT OF PRESENT HOME:______________________________________

COMMENTS:

DISPOSITION OF DOG: