| First Name: |
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| Last Name: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Daytime Phone: |
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| Evening Phone: |
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| Email: |
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| What type of pet are you interested in?: |
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How do you plan to use (house pet, hunting, agility) and house (indoors, outdoors, fenced yard, etc.) this dog?
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| What other pets do you have in your home?: |
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| Please list family members and ages.: |
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| How much time will this dog spend alone each day?: |
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| ...with other dogs?: |
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| Current or prior veterinarian reference: |
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| Have you ever been convicted of a crime involving cruelty to animals? If Yes, explain.: |
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| Will you allow a follow-up visit by Olive's Hope: |
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| Signature: |
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| Date: |
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