First Name MI Last Name Street Address City State Zip Cell Phone Home Phone Email Maiden Name Date of Birth (MM/DD/YYYY) Driver's License # Date: Time: I am interested in fostering (Please specify preferences such as size, breed, M/F, adults vs puppies, litters, bottle feeding, etc.):

First Name MI Last Name Maiden Name Date of Birth (MM/DD/YYYY) Driver's License # Cell Phone Home Phone Email Relationship with APPLICANT

Length of time at current residence (years, months) If you are renting, please list the name and phone number of your landlord Number of children in Household: Ages: Number of Adults in household: Street Address City State Zip Length of time at this residence (years, months)

Applicant Employer Phone Number Hours worked per week Shift Employed here for how many years, months Co-Applicant Employer Phone Number Hours worked per week Shift Employed here for how many yrs, months How many hours will the dog or puppy(s) be left alone? If other, please explain: If other, please explain: If other, please explain: If other, please explain: Name Breed Temperament Age Length of ownership Vet Clinic Used Clinic City & Phone Number Name Breed Temperament Age Length of ownership Vet Clinic Used Clinic City & Phone Number Name Breed Temperament Age Length of ownership Vet Clinic Used Clinic City & Phone Number Name Breed Temperament Age Length of ownership Vet Clinic Used Clinic City & Phone Number Please list any other current pets Electronic Signature: Date Electronic Co-Applicant Signature: Date