HUMANE SOCIETY OF BEAVERHEAD COUNTY
                         DOG ADOPTION QUESTIONAIRE
 
DATE ___________   Impound Number ____________  Dog Name _____________

PERSONAL INFORMATION:

Name:_____________________________________  Home Phone:_______________

Address:______________________________________________________________

Email:________________________________________________________________

City:__________________________________  State:_____  ZIP:____________

How long at this address?__________  If less than 2 years, please list

  your previous address:______________________________________________

Married:_____    Single:____   Live with parents:______   Age:________

No. of children in the home:_________  Ages:__________________________

Name of employer:_______________________________  Phone:______________

Name of spouses employer:_______________________  Phone:______________

Does anyone in your family suffer from allergies? ____________________

Have you adopted from the HSBC Shelter before?____

RESIDENTIAL INFORMATION:

RESIDENCE:   House:____  Apartment:____  Condo:____  Mobile Home:____

Landlord's name:________________________________  Phone:______________

Besides your immediate family, are there others residing in your home?

  Yes:____  No:____  If yes, who?_____________________________________

Does your home have a yard?____  Is there a fence?____  Type of fence

and how tall?_________________________________________________________

If the yard is fenced, when the gate is closed, will the dog be

completely enclosed? _________________________________________________

ADOPTION INFORMATION:

Have you ever owned a dog?____________________________________________

What is the longest period of time the dog will be left alone?________

Where will the dog be kept during this time?__________________________

If kept outside, will there be a dog run/dog house?___________________

Will you take your dog to obedience classes, if needed?_______________