Your full name:

Your email address: (e.g.: you@aol.com)

If you are interested in a specific dog, please list dog's name here:

Address

City, State, Zip

Home Telephone

Work Telephone

Cell Phone

Occupation

Type of Home (house, apartment, etc.)

Do you rent or own?

If renting, list name and telephone number of Landlord or apartment complex.

Are there any restrictions on the number or type of dogs you are allowed to have? If so, list.

Do you have a fenced yard?
Yes
No

If yes, what kind of fence is it? (wood, chain link, etc.)

If yes, how tall is the fence?

How many hours will the dog be left home alone on days you are working?

Please list all members of your household and their ages.

Please list all pets currently residing in your household and their breeds/ages.

If you currently have dogs or cats, are they spayed/neutered?

Vet Reference: Please list the name and telephone number of your Veterinarian (and the name your pet's records are under if different than above.)

Other Reference: If you did not list a Veterinarian above, please list the name and number of another reference (friend or relative).

Have you ever had to give up a pet? If so, what were the circumstances?

Please check below all characteristics that you are interested in:

Breed
Purebred Shiba Inu
Shiba Inu mix (under 30 lbs.)
Purebred Jindo
Jindo mix (under 45 lbs.)
Other. List dog interested in:

Gender

Female
Male

Age

Under 1 year old
Adult
Senior

Color

Red
Red Sesame
Black & Tan
Cream

How long have you been considering adding a new pet to your household?

What are your reasons for wanting a new pet? Please check all that apply.
Pet for child
Playmate for existing pet
Gift
Companion for self
Hunting
Protection
Breeding
Participate in agility classes
Other - List:

My pet will spend most of its time:
Indoors
Outdoors

When no one is home, where do you anticipate your pet will stay?
Allowed loose indoors
In a restricted area indoors
Crated indoors
Outdoors in fenced yard
Outdoors in dog pen
Outdoors on tie-out or chain

If your pet will spend a substantial amount of time outdoors, what type of shelter will be provided?

Who will be primarily responsible for the care and training of your new pet?

What is the ideal activity level you'd like your new pet to have?
Non-stop energy / lots of drive
On the energetic side
On the calm side
Couch potato

Is it important for you to be able to let your dog run off-leash in parks, at the lake, etc.?
Yes
No

What behaviors are you absolutely unwilling to accept? Check all that apply.
Excessive Barking
Marking in house
Digging in yard
Destructive chewing
Repeated attempts to bolt out of doors
Repeated attempts to escape yard

What would you do if a pet you adopted started to display any of the unacceptable behaviors above?

Would you be willing to attend obedience classes with your new pet?
Yes
No
Only if needed

There are times when unexpected and often expensive medical treatment may become necessary for your pet. What will you do if faced with this situation?

Are you willing to let a representative of our group visit your home?
Yes
No

By clicking "Submit" below, you hereby certify that the information contained above is true and correct.