Date Submitted:____________________________

NAME: ____________________________________ ADDRESS: ____________________________

CITY: _______________________________________ STATE: _____ ZIP: ______________________

PHONE: (Home): _______________________________ (Work)_______________________________

E-MAIL ADDRESS: ____________________________ FAX NUMBER: _________________________

BEST TIME TO CALL: __________________________ OCCUPATION: _________________________

DO YOU RENT OR OWN? ___________________ (Circle One): House Apartment Trailer Other: ___

IF YES TO RENT, WHAT IS THE PHONE NUMBER OF YOUR LANDLORD? ___________________

DO YOU HAVE A FENCED HOME OR AREA FOR THE DOG? (Please describe): _________________

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IF NO, WHAT ARRANGEMENTS WILL YOU HAVE FOR THE DOGS’S EXERCISE AND TOILET DUTIES? (Describe)_________________________________________________________

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PERSONAL DATA

AGE: _____ MARITAL STATUS _____ IF MARRIED, DOES HE/SHE KNOW OF AND APPROVE OF

THE DOG? _____ ANY CHILDREN? ________ IF YES, WHAT ARE THEIR AGES? ______________

DO YOU OWN OTHER DOGS AND OR CATS? _________ HOW MANY? ______________________

LIST BREED, SEX, AND AGE OF EACH DOG THAT YOU OWN: _____________________________

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ARE THEY SPAYED/NEUTERED? ______________________________________________________

YOUR CURRENT VETERINARIAN: _____________________________________________________

ADDRESS: ____________________________________ PHONE: _____________________________

HOW MANY HOURS ON THE AVERAGE WILL THIS DOG SPEND ALONE AT YOUR HOME? ___ _________________________________________________________________________________

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IF YOU HAVE HAD A DOG BEFORE, DESCRIBE THE LAST DOG YOU OWNED AND WHAT HAPPENED TO IT? __________________________________________________________________

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WHY ARE YOU INTERESTED IN OWNING YORKSHIRE TERRIER? __________________________

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ARE YOU FAMILIAR WITH THE CHARACTERISTICS AND TEMPERAMENT OF THE

YORKIE? _______ HOW ABOUT THE GROOMING AND MAINTINANCE OF THE

Yorkie ? _______ IF NO, ARE YOU WILLING TO LEARN ?__________

HAVE YOU EVER OWNED A YORKIE BEFORE? ________ A TOY BREED? __________

ARE YOU COMMITTED TO CARING FOR THIS DOG FOR ITS LIFETIME? _____________________

WHERE WILL THE DOG STAY DURING THE DAY? _______________________________________

AT NIGHT? ______________________________________________________________________

DO YOU HAVE A PREFERENCE OF SEX, ? ________________

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HAVE YOU EVER RAISED A PUPPY BEFORE? _________________________________________

DO YOU CONSIDER YOURSELF FINANCIALLY STABLE ENOUGH TO PROVIDE PROPER DIET,

AND MEDICAL CARE FOR A YORKIE, INCLUDING EMERGENCY TREATMENT IF

NEEDED? _____________________________________________________________________

ARE YOU AWARE THAT THEIR IS AN ADOPTION FEE OF $________ WHICH WILL SUPPORT FUTURE RESCUES OF YORKIES? __________________________________________

WOULD YOU BE WILLING TO ALLOW A COMMITTEE MEMBER OR APPOINTEE TO VISIT YOUR HOME BY APPOINTMENT? ___________________________________________ _______________________________________________________________________________

PERSONAL REFERENCE: ___________________________________________________

RELATIONSHIP: _____________ ADDRESS: __________________________________________

PHONE: ____________________

Please use the bottom of this sheet to add any other information you wish us to consider in placing a Yorkie with you. Thank you again, your interest is deeply appreciated.

SIGNATURE: _________________________________________ DATE: ______________________