Your e-mail address:

Your street address:

Your City, State, and Zip Code:

Home phone:

Cell phone:

Have you owned a poodle before?
Yes
No
I have one or more now

Have you ever been convicted of an offense involving animals?
Yes
No

If yes, please explain in the Comments section below.

In which dog are you interested? Please select from the list below.
Choose a name from the list. Meagan

Please list every dog you currently own by name, breed, and age. Please also indicate whether or not your dog(s) has been spayed or neutered with an S or an N.
Write "none" if you don't currently have a dog.

Please list all the animals other than dogs that you currently have. Write "none" if you have none.

If you have a dog or dogs, will your veterinarian verify they have current vaccinations and are on heartworm preventative?
Yes
No
Current on shots but not on heartworm preventative
I don't have a dog

As an adult, have you ever owned a dog that was hit by a car?
Yes
No

If you answered Yes to the previous question, please explain below.

Is everyone in your household enthusiastic about getting a new dog?
Yes
No
Not yet

Do you have any physical limitations, pet allergies, or other mental or physical health issues that would affect your ability to care for a poodle?
Yes
No

If you answered Yes to the previous question, or if anyone in your household has pet allergies, please explain below.

Who will be the primary caretaker?

Please list the residents of your home. If there are children, please include their ages. Example: husband, son 15, daughters 12 and 9, mother-in-law.

On average, how many hours per day at a time would the dog be left alone? If more than six hours, please explain in the Comments section below how the dog will have the opportunity to go to the bathroom.

If you adopt a Utopia poodle, do you agree to keep it as an in-home companion?

Do you own or rent your present home?
Own Rent

If you rent, will you be able to provide a written statement from your landlord indicating you're allowed to have a dog, or a copy of your rental agreement which indicates you're allowed to have a pet?
Yes
No
Not applicable - I own

Please indicate your type of residence.
House Duplex Apartment Condo/Townhouse Mobile home

Are you willing and able to pay for veterinary expenses, both routine (booster shots, examinations, heartworm preventative, flea control products) and unexpected (broken leg, surgery, reaction to chemicals)? Please consider this carefully.
Yes No Probably Depends on the amount

The name and phone number for your current veterinarian, or the vet who cared for your last dog.

The name and phone number for the veterinarian you plan to use for Lia, if different from above. If you don't have a vet, I will need you to choose one before I can approve your application.

I do not ship adult dogs - you must come meet them in person. Are you within driving distance of Waycross, GA?
Yes.  No

Comments, questions, or additional information? Please feel free to write as much as you want here.

By entering your name below, it is as if you are placing your signature. You affirm that all the information you have given is truthful and correct.

Signed:    Date: