Applicant: Please provide the following contact information

Name:

Address:

Address (cont.):

City/ State/ Zip:

Home Phone:

Work Phone:

Cell Phone:

Email:

1. Why do you want a Corgi?

2.Do you have a fenced yard?   Yes    If no fence, what arrangements will you have for the dog's exercise and toilet area?

3.Where will this Corgi spend the majority of it's time (daytime? nighttime)?:

4.Have you previously owned a Corgi?   Yes    If so, for how long?

5.any current or past activities with dogs? (Check all that apply)    Clubs    Training    Showing    Breeding

6.This Corgi will be? (check all that apply)    Companion pet    Watch dog    Working dog    Gift    Companion another dog

7. Corgi Preferences:    Young adult    Adult    Senior    Any    Gender?

8. Household (check all that apply)    Own   Rent    House  Condo  Apt.  Mobile home    Rural  Urban  Subdivision

9. Family:    Number of Adults in household     How many Children in household?   Ages?

10. Current Pets: (Please provide the following information)   Current Pet 1    Species     Breed     Age     Gender    Spayed / Neutered?     Current Pet 2    Species     Breed       Age     Gender    Spayed / Neutered?     Are all pets current on vaccinations?     If no, please explain:       Are all current pets on flea/tick/heartworm preventative?   Please provide name and contact information for veterinarians   your pets have seen in the past 10 years:

11.Have you ever surrendered a dog to a rescue group?       If yes, please explain:       Are you willing to have a home visit prior to the adoption?      Are you willing to housetrain this dog if necessary?      The majority of rescue Corgis are 4 years and up.