First Name *

Last Name *

Street Address *

City *

State/Province *

Zip/Postal Code *

Day Phone *

Night Phone

Cell Phone

E-Mail *

What type of housing do you live in? Apt/Condo
Townhouse
Single Family Home
*

Do you own or rent? Own
Rent
*

If you rent, does your landlord permit dogs? Yes
No
Not Sure

If you rent, is there a weight/size limit on allowable dogs? Yes
No
Not Sure

If yes, what is the weight/size limit?

Do you have stairs in your home? Yes
No
*

If yes, how many stairs?

Do you have a fenced in yard? Yes
No

If yes, please describe your fence:

If no, do you agree to keep the basset on a leash when outdoors? Yes
No

Are you willing to have a volunteer from All Ears Basset Sanctuary visit your home prior to adoption? Yes
No
*

Do you have a veterinarian? Yes
No
*

What pet name and last name are your current vet records under?

Why do you want to adopt a Basset? *

Will this be your first dog/basset as an adult? Yes
No
*

Have you ever adopted a dog from a rescue organization or shelter? Yes
No
*

Have you ever had to give up a dog? Yes
No
*

If yes, please explain:

How do other family members feel about adopting a Basset? *

Which family member will be the basset's primary caregiver? *

How many hours per day will the basset be left alone? *

Where will the basset be kept during the day? *

Where will the basset be kept during the night? *

Are you willing to provide the required heartworm preventative on a monthly basis? Yes
No
*

Are you willing to provide us with follow up reports? Yes
No
*

Do you agree to return your basset to All Ears Basset Sanctuary if you are unable to keep it? Yes
No
*

Would you prefer a male or female basset? Male
Female
No Preference
*

What age Basset do you prefer? (Select all the age(s) that apply.) No Preference
Puppy to 24 Months
2 - 5 Years Old
5 - 8 Years Old
8 - 10 Years Old
Senior
*

Would you consider adopting a Basset mix? Yes No Maybe *

What specific traits are you looking for in a basset that would make him/her the right match for your family? *

Have you ever taken a dog to obedience training? Yes
No
*

Are you willing to take your basset to obedience training if necessary? Yes
No
*

Are you willing to house train your basset, if necessary? Yes
No
*

Are you willing to crate train your basset? Yes
No
*

Is there a specific dog or dogs in which you are interested?

How were you referred to us?

If you have other comments please indicate below.