Are you applying for a specific dog? Yes No

What is the dog's name and location?

Gender No preference Male Female

Age Puppy - 1 year 1 - 3 years 3 - 5 years 5 or older No preference

Type of Fox Terrier? No preference Wire Hair Smooth

Describe your activity level: Extremely active Moderately active Somewhat active Not active

Marital Status Married Single Live with parents Couple, not married Military

Have you ever owned a Fox Terrier before? Yes No *

Do you still have the dog or what happened to it?

Where or from whom did you get your Fox Terrier from?

Have you ever spent any time with one? Yes No *

How did you learn about Fox Terriers and why did you decide on this breed?

Do you have any other pets or livestock? Yes No *

Please supply name, breed, gender, age and neuter status of other pets:

What dogs have you owned previously and what happened to them?

Have you or any immediate family members ever surrendered a dog to a rescue group, humane society or animal shelter? Yes No *

Please explain the circumstances:

Has your ownership of a dog ever caused you to be in a court situation? Yes No *

Please explain:

Do you have any children living in the home or who are in the home on a regular basis? Yes No *

Please list their age(s):

What type of dwelling do you live in? House Apartment Duplex Condo

Do you own or rent? Own Rent *

Please provide your landlord's name:

Please provide your landlord's telephone number:

Do you have a fenced in yard? Yes No *

What type of fencing and how high?

Do you have a swimming pool? Yes No

Is it separately fenced? Yes No

How often and for how long is there regularly no one at home?

Where would the dog be during those hours?

Where will the dog stay at night?

Who will care for dog on a regular basis?

Please list other persons in household besides those listed in the first question who will have contact with dog:

Does this person approve of getting a dog? Yes No

On vacations, what would you do with the dog?

How will the dog get exercise?

Do you plan to do obedience training with the dog if he/she is not already trained? Yes No

How would you help your rescue Fox Terrier adapt to its new home and how would you introduce it to your rules and expectations, including where and when to go outside?

Some rescue dogs are untrained and not housebroken. Are you willing to take a dog like this? Yes No *

Are you familiar with crate training? Yes No *

Would you be willing to take a dog with minor health or behavioral conditions? Yes No *

All dogs must be spayed or neutered as part of the adoption process. Are you willing to do this if not already been done? Yes No *

When will you be ready to take possession of the dog? Calendar

If there are no dogs available in your area, are you willing to have a dog transported from another area? Yes No *

What is your closest major airport?

Would it be o.k. with you to have a member of American Fox Terrier Rescue visit your home? Yes No *

Please tell us a little about yourself and your lifestyle so that we can match the right Fox Terrier to your home.

Veterinary reference (name and phone):