First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County

Email*

Home Phone

Cell Phone*

Are you...*
Choose one: Married Partnered Single

What is your partner's name?*

Please list the names and ages of children in the home*

Do any children, under 8 years old, visit your home frequently?*

Which best describes your residence?*
Choose one: I own my apartment I rent my apartment I live with roommates in an apartment I own my condominium I rent my condominium I live with roommates in my condominium I own my house I rent my house I live with roommates in a house

Do you have a fenced yard?

What is the height of the fence*

Please describe your fenced yard (4ft chain link, 6ft privacy, etc). *

Will the animal be kept inside or outside*
Choose one: Inside Only Outside Only Inside and Outside

Does your home have stairs inside or out? How many approximately?*

How many hours will the dog be left alone?*
Choose one: 1 - 4 hours per day 5 - 8 hours per day 9 - 12 hours per day 13+ hours per day

Where will the animal sleep*

Where will the dog be kept while the humans are at work?*

Are you interested in a particular dog or a certain breed? List their name and/or breeds that you're interested in.*

Is there a breed type you do not want?*

Are you willing to work with a dog that is not housebroken?*

What other pets do you have? Please list species, breed, and age.*

Are pets in home spayed or neutered (no will not exclude fostering/adopting) If no, give reasoning*

List at least one reference (who is not a family member)*

If you rent, have you received the approval of your landlord to have an animal*
Choose one: Yes No

What is the best day for a home check? (hold down CTRL to select more than one)
Choose all that apply: Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Best times for a home check? (hold down CTRL to select more than one)
Choose all that apply: 6:00am - 10:00am 11:00am - 2:00pm 3:00pm - 7:00pm 8:00pm - 10:00pm

How did you hear about Res-Que?