Have you ever been convicted of a felony? YES NO 

Interested In (dog’s name):

Today’s Date: DAY12345678910111213141516171819202122232425262728293031 MONTHJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember YEAR20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989

PERSONAL INFORMATION

First name:

Last name:

Birth date: DAY12345678910111213141516171819202122232425262728293031 MONTHJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember YEAR200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940

Social Security Number:

Drivers License Number:

E-mail:

Street Address 1:

Address Line 2:

City:

State:

Zip:

HOUSING

Type of housing: SELECTApartmentCondoHouse

Can you provide a copy of lease (if applicable): YES NO 

Landlord’s name :

Landlord’s phone number :

Years at current address: SELECT1234567891011121314151617181920

If under 2 years, previous address:

Home phone number:

Cell phone number:

Marital status: SELECTSingleMarriedOther

How many adults in the house: ---01234567

Name, age and relationship of other adults:
1.
2.
3.
4.
5.

How many children in the house: ---012345678

Age of children:

Do you have a fenced yard or kennel run? YES NO 
If so describe:

Does anyone in the home have allergies: YES NO 

Do all the adults in the house want a pit bull? YES NO 
If not, who and why:

Are there other dogs in the house? YES NO 
If so please provide breed, sex, age and if they are spayed/neutered:

Any cats in the house: YES NO 

How many other animals have you had in the past 5 years:

Where are they now? Still alive, put to sleep, given away, lost, hit by a car:

WORK

Employer address :

Employer phone number :

Years at employer: ---12345678910more

Typical hours worked:

CARE

How will you handle exercise and potty needs:

How many hours will the dog be left alone: ---0123456789101112131415161718192020+

Who will be the primary caregiver of the dog:

Why do you want a pit bull:

Describe your lifestyle:

Where will the dog live primarily:

What activities will your dog participate in:

Will you crate your dog when needed? YES NO 
If no, why:

How will you handle mischievous behavior, digging, chewing, etc:

How will you handle any unwanted behavior:

What would cause you to return the dog:

Are you prepared for the personal attention this breed needs: YES NO 

Do you have the time and ability to train and exercise a strong, large dog: YES NO 

Are you ready to commit the next 10-16 years to this dog: YES NO 

Current vet’s name:

Current vet’s address:

Current vet’s phone number:

REFERENCES

Please provide 2 personal references (not relatives)
1.

Name:

Address:

Phone number:

Relationship:

2.

Name:

Address:

Phone number:

Relationship:

Please provide 2 family members who will know your whereabouts for the next 5 years:
1.

Name:

Address:

Phone number:

Relationship:

2.

Name:

Address:

Phone number:

Relationship:

THE INFORMATION ON THIS APPLICATION WILL BE KEPT CONFIDENTIAL.

BY SUBMITTING THIS APPLICATION, I CERTIFY THAT ALL INFORMATION PROVIDED IS COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT YOU MAY RUN A BACKGROUND CHECK AND WILL CHECK ALL MY REFERENCES.

AGREE and DIGITALLY SIGN.