First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Cell Phone

Volunteer Name*

Volunteer E-mail*

Date of Home Visit*

Home Setting
Choose all that apply: Rural Urban Suburban Other

In what type of home is this?
Choose all that apply: Apartment Duplex Other Single Family Townhouse/Condominium

Does applicant own or rent home?*

Overall assessment of home? (safe/some hazards/numerous hazards/unsafe/other - please explain)*

What is the applicant looking for in a Doberman/dog? Color, age, sex, activity level, specific looks such as docked or cropped, cat savvy, good with children, protective, barker, none-barker, be specific! *

What reasons or behaviors would you return a dog? Biting, barking, counter surfer, chewer, not house broke, digs holes, leash reactive, health issues, ect....

Does applicant have past experience with Dobermans?*

Is there a yard?*

If there is a yard, is it completely fenced?
Choose all that apply: Yes No Not Applicable

What is the height of the fence?

What type of fence do you have?
Choose all that apply: Chain Link Invisible No fence Other Partial fence Privacy

If no fence, please explain your plan in detail how dog will be allowed to bathroom and play outside.

Plan for exercise

What are your concerns (if any) after visiting the home? Were they resolved at end of home visit?*

Were any children or pets present during your visit? Describe interaction with you home visit person and any dog you brought with. *

General information - please provide a basic summary of the family environment.*

How do you plan to train and discipline dog?*

Has applicant provided registration confirmation of obedience class, or has applicant determined a training facility for future training?*

Is applicant familiar with crate training and are they willing to crate dog?
Choose all that apply: Yes No Not Applicable

Are there other pets in the home? Please list type, dogs, cats ect, Sex of animals and if altered or intact. *

Where will the animal sleep? *

Are current, or past pets spayed or neutered?*

Are applicant's current, or past pets, on heart worm preventative?*

What happened to previous pets? Explain in detail*

Where will animal be kept when not home?*

Would you feel comfortable leaving your dog with applicant? Please explain.*

Please provide a summary and describe anything else that should be noted when considering applicant.*