Stickney Toy Breed Rescue and Retirement Sanctuary

5675 S.W. 42nd Road

Cortland, Ne 68331

402-613-4306/mary@stickneys.net

ABOUT YOU

Names of all adults in household:

APPLICANT:        First Name     Last Name

CO-APPLICANT:   First Name     Last Name

Address:

City:      State/Province:      ZIP/Postal Code:

Email Address:

Home Phone:      Work Phone:

Best Time to Call:    Where? Home Work

Number of persons in your household and their ages:

Adults:      Children: 

ABOUT YOUR HOME

Type of Dwelling   House  Apartment      Trailer 

Do you Own   or  Rent  your home?

If you rent, do you have your landlord's permission to keep a dog?     Yes    No

(We will require a letter from your landlord evidencing this permission.)

Do you have a yard?     Yes    No

If yes,   How large is your yard?

Is your yard fenced?     Yes No    If yes, how high is the fence?

Do you have a dog kennel run?     Yes     No  

If yes, how large is it?

If yes , do you plan on the dog living 100% of the time in the kennel?   Yes   No

Where will the dog sleep?

Do you plan to use a dog crate?     Yes     No

If yes how many hours per day will the dog be crated?

Please explain why or why not? 

Are there currently animals in your home?  Yes     No

List current animals:

RESCUE DOG PREFERENCES

Please indicate here any preferences you have for adopting a rescued:

I would prefer a:     Male     Female     Either gender rescue dog.

Would you be willing to adopt a dog with health problems (non-infectious)?   

  Yes    No

If yes, to what extent would you be willing to help a sick dog? 

List your personal and Veterinary References here: