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Personal Information:
  Name:
  Address1:
  Address2:
  City:
  Zip:
  Email:
  Day Phone:
  Evening Phone:

Please complete the following questionnaire:

1. Have you ever owned a Yorkshire Terrier? Yes | No
  If yes,
    for how long?
    Do you still have this dog? Yes | No
    If no, what were the circumstances of the loss of the dog:


2. Why do you want a Yorkshire Terrier?
   

3. How many adults in your household? How many children? Ages:

4. Do you presently have other pets? Yes | No
  If yes, what kind, how old, how long have you had them?
   

5. Do you have a local veterinarian? Yes | No
  If yes,
    Name:
Phone Number:

6. Are you willing to permit a rescue team member to visit your home? Yes | No

7. Do you live in a house? or Apartment?

8. Do you have a fenced area? Yes | No
  If no,
    Would you be willing to enclose your yard or a portion thereof for the dog’s safety? Yes | No

9. Do you agree to provide all necessary veterinary care for the dog including vaccinations, and general healthcare?
Yes | No

10. Preferred sex of dog: Male | Female | No preference

11. Preferred age of dog: Under 3yrs | 3-6 yrs | 6-9yrs | Senior (9+)

12. Our Rescue sometimes takes in special needs yorkies such as yorkies with diabetes or yorkies with digestive conditions. Would you be willing to accept a dog with special dietary needs or medical conditions requiring special treatment? The specific condition and/or special needs of the dog would be discussed prior to adoption.
Yes | No

13. Please provide two personal references:
  1 Name: Phone: Time known:
  2 Name: Phone: Time known:

I (we) represent that I (we) have never been subject to legal action for cruelty to, or neglect of, animals. I (we) represent that I (we) have never owned an animal that has been confiscated by any animal control or humane organization for violations of animal control regulations or animal adoption agreements.
I (we) swear that the information contained above is true and correct to the best of my knowledge.

Signature of applicant: Date:

 
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