Forms

Success Puppy/Dog Application

In order to be considered for a Purchase or adoption you must:

1) Complete and submit this application to Nancy Sedlacek.

2) be at least 19 years of age

3) have the knowledge and or consent of all adults living in your household

4) have a valid ID with current address.

5) understand that completing this application does not guarantee purchase/adoption of a puppy/dog from         Success PWD/PWD.

Name:______________________________________________________________________

 

(Please print name of spouse/housemate, also)

Address:_____________________________________________________________________

 

Home Phone:_________________________ Work Phone:_____________________________

 

Cell Phone:___________________________ Email:__________________________________

 

Do you: Attend School:_____  Work:_________ (at home or away)?_____________________

 

Employer:____________________________________________________________________

 

Do you live in a: house:____ Apartment:____ Condo:____ Dorm:____ Mobile Home:_____

 

Do you: Rent:____ Own:____ Live with parents:____ 

 

Landlord’s Name & Address:_______________________________________ Phone:_________

 

How long at current address:_______ If less than one yr. please list previous address:

 

_____________________________________________________________________________

 

Please provide the following information about your household: Number of Adults:_____ 

 

Number of children and ages:______________________________________________________

 

Who will be primarily responsible for the care (feeding/grooming/training) of your new pet?____

 

Why would you like to adopt a pet from us? Please check all that apply: Companion:_____

 

Gift:___ Guard/watch dog:______ Companion for other pet:_______ Other:________________

 

How many pets do you have currently: Cats:___________________________________________

 

Dogs (& name breeds):______________________________________________________________

 

How many pets have you had in the last 10 yrs.___________________________________________ 

 

NAME TYPE/BREED AGE   SEX

(Continue on back of sheet if necessary)

 

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Have you ever adopted an animal from a shelter? If yes Where?______________________________

 

Are your pet’s vaccinations current as well as other Veterinary care needs? ____________________

 

Name of Veterinarian/clinic used for your pets, address and telephone:_____________________________________________

 

_____________________________________________________________________________________

 

Do you plan to use the same Veterinarian for your new dog?_______ If not, who are you planning to use?

 

________________________________________________________________

 

How much do you anticipate spending yearly on food, Vet care and other expenses for your dog? 

 

______________________________________________________________________________

 

Do any members of your household have allergies?____ To what?________________________ 

 

Do you have any plans to move in the near future?_______ If at some time you do move, what will you do with your dog?________________________________________________________

 

Will it be acceptable for Nancy Sedlacek, to call or come to your home, to check on the dog, if she is visiting in your area?________________________________________________________

 

How much time will this dog be alone (without human companionship) Hours_____ Days of week:______________________________________________________________

 

Will your dog stay: Primarily inside:_____ Primarily outside:_____ Outside Only:______

 

Where will the dog be kept when home alone?______________________  How often?________

 

Where will you exercise this dog?________________________________ How often? ________

 

Do you have a completely fenced in yard? 

What type of fencing?_________________________

What food will you feed?________________________ How often will you groom/brush?_____

 

Describe how you will housebreak a dog?____________________________________________

 

____________________________________________________________________________________________________________________________________________________________________________________________________,

 

or if not fenced, will you use a leash? All of the time:___ Almost always:___ Never:____

 

How will you discipline or correct your dog?_________________________________________

A dog can live will over 10 years of age and requires a major commitment of time, finances and emotion.  Are you willing to make that kind of commitment at this time?___________________

 

Age of dog requested:________________ Sex:_________________ Color:_________________

 

Coat Type:_________________________ Any additional specifications: ___________________

By signing below, I certify that the information given is true and correct and I recognize that any misrepresentation my result in my losing the privilege of adopting/purchasing a dog from Nancy Sedlacek. I also give my Veterinarian release of any Veterinary care records and information regarding my current and past pets to Nancy Sedlacek.  I understand that this dog is the property of Nancy Sedlacek and she had the right to deny my request to adopt/purchase. This application is valid under the privacy act and will not be reproduced.

Personal References: (Names/address/telephone)- non-relation please.

1)____________________________________________________________________________

 

2)____________________________________________________________________________

Signature:__________________________________________________ Date___/___/_____

 

Signature:__________________________________________________ Date___/___/_____