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Your Name:
Spouse Name:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone
Occupation:
Email Address:
Do you:	Own Rent Live with Family/Friends
If you Rent - Landlord's name:
Landlord's Phone:
How many adults live in the home?:
How many children live in the home?:
Children's ages:
1st Reference name:
1st Reference Home Phone:
1st Reference Work Phone:
1st Reference Cell Phone:
Years acquainted with 1st Reference:
2nd Reference Name:
2nd Reference Home Phone:
2nd Reference Work Phone:
2nd Reference Cell Phone:
Years acquainted with 2nd Reference:
Current/Last Veterinarian's Name:
Name of Veterinarian's Clinic/Animal Hosptal:
Veterinarian's Phone:
Do you currently own any dog(s)?	Yes No
Dog #1 Name:
Dog #1 Breed:
Dog #1 Age:
Dog #1 Sex:	Female Male
Is Dog #1 Spayed/Neutered:	Yes No
IF NO, Why Not?:
Date of Dog #1 Last Heart Worm Test:
Is Dog #1 given Heart Worm Medication Monthly?:	Yes No
If NO, Why Not?:
Where does Dog #1 spend most of each day?:
Dog #2 Name:
Dog #2 Breed:
Dog #2 Age:
Dog #2 Sex:	Female Male
Is Dog #2 Spayed/Neutered:	Yes No
If NO, Why Not?:
Date of Dog #2 last Heart Worm Test:
Is Dog #2 given Heart Worm Medication Monthly?:	Yes No
If NO, Why Not?:
Where does Dog #2 spend most of each day?:
Dog #3 Name:
Dog #3 Breed:
Dog #3 Age:
Dog #3 Sex:	Female Male
Is Dog #3 Spayed/Neutered:	Yes No
If NO, Why Not?:
Date of Dog #3 last Heart Worm Test:
Is Dog #3 given Heart Worm Medication Monthly?:	Yes No
If NO, Why Not?:
Where does Dog #3 spend most of each day?:
What Brand(s) Heartworm Preventative Do You Currently Use?:
Do You Currently Own Any Other Pets or Livestock?:	Yes No
Tell us about your other Pets:
How many other animals (cats/birds/horses/etc) have you owned in the last 5 years?:
Are your other animals Spayed/Neutered?:	Yes no
If NO, Why Not?:
Have you ever owned a Boxer before?:	Yes No
How many Dogs have you owned in the last 5 years
What happened to your previous dog(s)?:
If you Adopt a Dog, where will the Dog spend most of each day?:
Where will the Dog sleep?:
Do you have a fenced yard?:	Yes No
If NO, how will you handle the Dog's daily toilet and excercise needs?:
How many hours will the Dog be alone each day?:
Do you have a Crate available?:	Yes No
Will you take the Dog to basic obedience training classes?:	Yes No
If NO, Why Not?:
Have you ever given an animal away, to a pound, animal shelter humane society or rescue group/organization, etc.?:	Yes No
If YES, Why?:
Have you ever Adopted as Dog from any pound, animal shelter, humane society, or rescue group/organization, etc?:	Yes No
If YES, What Breeds?:
Are you willing to Adopt a Boxer-Mix?:	Yes No
Are you willing to Adopt an Older Dog?:	Yes No
Are you willing to Adopt a Dog requiring Special Care?:	Yes No
Are you willing to Foster a Dog?:	Yes No
If you are willing to Foster, How Long?:	Short-Term Long-Term Either (doesn't matter)
Which Boxer Haven animal(s) are you interested in meeting?:
Please give us any additional information about yourself, your family and/or any present or past animals you've had that you think might be helpful to us in making a decision for adoption:
Do you agree to allow a Boxer Haven Agent visitation to your Home/Property prior to approval?:	Yes No
If NO, Why Not?:
Do you agree to a Boxer Haven Agent being able to meet ALL the People and ALL the Animals who Currently Reside in your Home and on your Property?:	Yes No
If NO, Why Not?: