Spouse/Partner Information

Spouse/Partner First Name:

Spouse/Partner Last Name:

Spouse/Partner Birthdate (mm/dd/yyyy format):

Spouse/Partner Phone:

Spouse/Partner Employer:

Spouse/Partner Job Title:

Spouse/Partner Length of Employment:

Children Information

Age & Gender of Children in Home: Age & Gender of Children that Regularly Visit:

Residence Information

Living Quarters: --None-- Single Family Home Town Home Duplex Condo Mobile Home Apartment

Rent or Own?: --None-- Rent Own Required

If you rent - Can we contact landlord?: --None-- Yes No

Landlord Name:

Landlord Phone Number:

Length of Time at Residence:

Yard Details: --None-- Yard with a Fence Yard with no Fence No Yard

If no fence, how will you exercise dog?:

Length of Time Dog is Alone: Required

Where will the dog be kept?:

Other Dogs/Animals Information

Other Animals:

Are your other animals Altered?:

Have you ever lost, stolen or given away a pet: --None-- Pet Lost Pet Stolen Pet Given Away

Explanation of Lost Pet:

Are your current Pets on Heartworm Prevention?:--None--Yes No

What Brand of Heartworm Meds are your pets on:

Name of Vet:

Vet Phone Number:

Have you ever been charged with Cruelty or Neglect: --None-- Yes No Required

Why Do You Want to Adopt?: Required

What Behavior would you deem Unacceptable:

Are you aware of the Breed Specific Health Risks?:

What Research have you done on owning a boxer:

Would you be willing to Adopt a Special Needs Boxer: --None-- Yes No

What Age of Dog:

If needed, do you agree to consult with a trainer and go to classes? --None-- Yes No

How Did You Hear About CBR: --None-- Web Friend/Family Event

References (Cannot be family members)

Reference 1 Name:

Reference 1 Relationship:

Reference 1 Email:

Reference 1 Phone Number:

Reference 2 Name:

Reference 2 Relationship:

Reference 2 Email:

Reference 2 Phone Number:

Reference 3 Name:

Reference 3 Relationship:

Reference 3 Email:

Reference 3 Phone Number: