Please complete this entire form. This information will be used to help place your dog. Click on the Submit button at the bottom of the page when ready to send.

Please note, a picture of the dog MUST be included. Please email it to the rescue coordinator at rescue@jnmrf.org or mail a snapshot with the dog's name on the back to

JNMRF
PO Box 65
Mendenhall, PA 19357

Your name:

Email address:

Phone Number

Your street address:

Your city and state:

How would you like to be contacted?

Phone Email

Dogs name:

Dogs Age:
Years Months

Sex
Male Female

Why are you placing this dog?

Does this dog have papers?
Yes No

If yes, are you willing to provide a copy of the papers?
Yes No

Has the dog been spayed or neutered?
Yes No

Is this dog current on vaccinations?
Yes No

Is this dog current on heartworm check/prevention?
Yes No

What is the name, address and phone number of the vet you last used for this dog?

Does this dog have any known health problems?
Yes No

If you answered Yes, please give a brief description.

What city/state did you aquire this dog?
City State

Has this dog had an owner other than yourself?
Yes No

How long have you owned this dog?
Years

How did you obtain this dog?
Pet Shop Breeder Stray Gift Paper Humane Society Other

If the above answer was "Breeder". have you tried contacting them?
Yes No

What is the breeders name and location?
Breeders Name
Breeders location and phone number
City State
Breeders Phone Number
Breeders email address

Does this dog ride well in a car?
Yes No

Does this dog have a favorite game or toy?
Yes No
If yes, what is it?

Is the dog currently left alone during the day?
Yes No

If yes, how many hours a day?
Hours

Is this dog a picky eater?
Yes No

Which of the following BEST describes this dogs attitude toward cats?
Aggresive Tolerant but not playful Cautious/Reserved Happy/Playful Unknown

Which of the following BEST describes this dogs attitude toward other dogs?
Aggresive Tolerant but not playful Cautious/Reserved Happy/Playful Unknown

Which of the following BEST describes this dogs attitude toward children?
Aggresive Tolerant but not playful Cautious/Reserved Happy/Playful Unknown

What are the ages of the children this dog has been living with?
Ages

Does this dog enjoy or tolerate being bathed?
Yes No Never tried

Does this dog enjoy being brushed/combed?
Yes No Never tried

Is this dog primarily an inside or outside dog?
Inside Outside If you answered "Outside", how is the animal confined? Tieout or chain Fence Other

Has this dog had a problem with any of the following:
Running? Straying? Fence jumping? Digging?

Does this dog bark when left alone?
Yes No

Has this dog had obedience training?
Yes No

Is this dog completely housetrained?
Yes No Partially

If not, are there accidents:
Occasional Frequent

Has this dog ever been trained to use an indoor kennel (crate)?
Yes No

Is this dog destructive?
Yes No Yes, if left alone

Is there anything you don't like about this dog?
Yes No

If the answer was yes, please explain.

Is there ANYTHING else that a prospective adopter should know about this dog?
Yes No

If the above answer was yes, please explain.