Puppy Raiser Application Step 1 of 15 6% Name* First Last Co-applicant First Last If applicableEmail* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Township / BoroughPrimary Phone Number*Alternative Phone NumberEmployer*In you are not currently employed type 'none'Employed PositionIf applicableShifts Worked If applicable For more rows click the (+) button Housing InformationWould you permit a home visit prior to being matched with a puppy in training?*YesNoIn not please explain below in detailDetails if previous answer is noWould you permit a home visit after the puppy is placed with you?*YesNoIf not explain below in detailDetails if previous answer is noWhich do you live in?*HouseCondoApartmentMobile/Manufactured HomeDo you rent or own?*RentOwn Rental InfoInformation needed based upon a rental property.Do you have written permission from your landlord to train a service dog?*YesNoPermission will be required, if necessary please add notes or questions below.Notes / QuestionsLandlord's Name* First Last Landlord's Phone Number* Living ArrangementsNumber of adults living in your household*Name and age of all adults living in your household*NameAge For more rows click the (+) buttonNumber of adult males in your household*Number of adult females in your household*Number of children living in your household*If none enter 0Name and age of all children living in your householdNameAge For more rows click the (+) button Contact with ChildrenContact with children plays a large role in the training of puppies.If you do not have children in your home, would the puppy com into regular contact with children under 13 years old?*YesNoI have children under 13 living in the householdIf you answered 'Yes' above please fill out the form belowAgeHours of Contact per Week For more rows click the (+) buttonIf you answered 'No' above will you be willing to ensure that the puppy is exposed to and socialized with children under 13 years old on a regular basis?Please go into detail Household Member DetailsDetails about the people living in your householdDo all the household member know you are considering training an assistance dog?*YesNoIf not please explain belowIf pervious answer is no, please explainDo all household members agree to having an assistance dog training in your home?*YesNoThey do not know I am considering this yetDo any household members have allergies to animals?*YesNoDo not knowIf yes, please explain belowIf previous answer is yes, please explainDoes anyone in the household have temperament or behavior issues?*YesNoIf yes, please explain belowIf previous answer is yes, please explain Yard DetailsIs your yard fenced in?*Completely fenced inPartially fenced inYard is not fenced inI live in an apartment/condo fencing is not available Yard has no fence or partial fenceAre you willing to install a fence?*YesNoIf no, explain belowIf previous answer is no, please explain Fenced Yard DetailsDescribe your fence*Approximate square footage of fenced in area*Any other details you would like to share about your fenced in yard Other PetsDo you currently have any pets?*YesNoNo, but I used to have a dogI have other pets but have never had a dogI have never had any pets DogsBreedAgeSpayed/Neutered Please list all currently owned dogs For more rows click the (+) buttonCatsBreedAgeSpayed/Neutered Please list all currently owned cats For more rows click the (+) buttonOtherBreedAgeSpayed/Neutered Please list all current other type of pets For more rows click the (+) button Please explain what happend to the dog* Trainer DetailsWho will be the primary trainer?*NameAgeNotes Who and how will you excercise the puppy?*Are you familiar with crate training?*YesNoAre you aware that we do not allow any domiance based training methods?*YesNoDo you have any plans to relocate within the next 2 1/2 years?*YesNoWhere do you plan to relocate?Have you ever sold a dog?*YesNoWhy did you sell the dog?Have you ever given a dog away?*YesNoWhy did you give the dog away?Have you ever surrendered a dog to a shelter or rescue?*YesNoWhy did you surrender the dog?Do you understand your local and state ordinances concerning leashing?*YesNoHave you or anyone in your household ever been cited for leash law violations or animal cruelty?*YesNoWhy? Veterinarian InformationDo you currently have a primary veterinarian?*YesNoName of Doctor First Last Address of Veterinarian Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Personal References and NotesReference Information*NamePhone Number Please list AT LEAST one reference For more rows click the (+) buttonWould you like us to know any other information about your, your family, and why this colunteer position is right for you?
