Name of Applicant:

E-mail Address:

Street: Apt# :

City:

State: Zip:

Home Phone: Home Fax:

Work Phone: Work Fax:

Are you interested in adopting: Male Female Either

Would you consider adopting a Scottie Mix? Yes No

Have you ever owned a Scottie? Yes No

1. Do you live in a: House Apartment Other

2. Do you rent or own? Rent Own

3. Do you have a fenced yard? Yes No ...pool? Yes No

4. Do you have children? Yes No
List ages

5. Will this dog come in contact with children? Yes No

6. Where will this dog stay during the day?

7. Where will this dog be kept at night?

8. How many hours will the dog be alone?

9. Who will care for your pets while you are on vacation?

10. Other pets you CURRENTLY own: Type Breed Sex Age Spayed/Neutered

11. Other Pets you USED TO own AND
What happened to them?? Type Breed Sex Age Spayed/Neutered

12. Your Veterinarian's Name, Address and Phone Number
to be used as a Reference.

I ACKNOWLEDGE THAT ALL THE INFORMATION CONTAINED ON THIS APPLICATION FORM IS TRUE AND CORRECT. I UNDERSTAND AND AGREE TO PAY AN ADOPTION FEE TO HELP DEFRAY MEDICAL COSTS.