EmailMe Form - Tri-State Shiba Inu Rescue Inc

Name *

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code

Home Phone

### - ### - ####

Cell Phone

### - ### - ####

Email *

Age *

Occupation

Describe your current home *

House

Condo

Apartment

*

Rent

Own

Is your yard fenced? *

No Fence

Invisible Fence

Chainlink Fence

Privacy Fence

Are there any children in the household? *

Yes

No

Maybe someday

List the names and ages of all other people living in this household. Please include children. *

Does everyone in the household want a dog? *

Yes

No

They don't mind

Is there a particular dog(s) you are interested in?

Purebred Only

Shiba Mix is fine

Dog Gender

Male

Female

Doesn't Matter

Age Ranges (Check all that apply)

Please describe what you are looking for in a pet, any behavior issues you would consider ok, and if you would consider a "special needs dog".

Have you ever adopted from us before? If so, who , when and where are they now?

Where will the dog stay when you aren't home?

Do you currently have other dogs?

Yes

No

Please list other dogs. Name, breed, sex and age, spay/neutered?

List any other pets you have (species and number).

Are you familiar with the Shiba Inu Breed?

Yes

No

If yes, please tell us how.

Do you understand Shibas can NEVER be trusted off lead except in a securely fenced area?

Yes

No

I can train them better than that

Will you allow a home visit upon request?

Yes

No