Please enable JavaScript in your browser to complete this form.Name *FirstLastStreet Address *City *State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code *Home PhoneWork PhoneCell PhoneEmail Address *Who lives full time at this residence?Please provide name and age for each personWhich of the above will assume primary responsibility for the care of this puppy?Is this person employed full time for attending school full time?YesNoWhere does this person work/go to school?Will the puppy go to work/school with this person?YesNoHow often will this be possible?Are you able to obtain proper written approval to take the puppy to work/school with you?YesNoWhat will the puppy do while you are working/attending school?If the puppy cannot accompany you to work is there someone able to take the puppy outdoors for potty breaks and exercise every four hours?YesNoWhat is the greatest length of time that you will have to leave the puppy unattended?If you travel, what arrangements are you able to make for the care of the puppy?Are you physically able and willing to walk the puppy a minimum of two 30-minute periods each day?YesNoAre you willing to participate in weekly obedience classes, in addition to other training?YesNoAre you willing to spend a minimum of 30 minutes each day, in addition to walks, training and reinforcing good manners?YesNoAre you able to take your puppy into community settings at least three times per week?YesNoDo you have dogs with which the puppy will socialize with?Please include Name, Age and BreedAre your dogs leash trained?YesNoDo they socialize well with others?YesNoAre you willing to transport your puppy to scheduled immunizations and care for your puppy following spaying or neutering?YesNoDo you have a fenced in backyard?YesNoCan you make a 6 to 12 month commitment to raising a puppy?YesNoHave you ever raised or crate-trained a puppy?YesNoHave you ever re-homed or surrendered an animal to a shelter?YesNoIf yes, please explainHave you or any member of your family committed or been charged with animal cruelty?YesNoWhy would you like to be a volunteer Puppy Raiser?How difficult do you think it will be to say goodbye to your puppy at the end of his/her stay with you?What concerns do you have about raising a puppy in your home for 6-12 months?Reference #1 NamePlease list the names and contact information for three character referencesReference #1 RelationshipReference #1 PhoneReference #2 NameReference #2 RelationshipReference #2 PhoneReference #3 NameReference #3 RelationshipReference #3 PhoneType Full Name *By my signature, I certify that the above information is complete and correct, and that I am at least 21 years of age. I realize that any misinterpretation of facts may result in disqualification from the program.Submit