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Eligibility Interview Checklist- application

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Owners Name_____________________________Date__________

Home Ph#______________Cell Ph#_________________________

Employer________________Work Ph#_______________________

Emergency person to contact if we cannot reach you:

___________________________________________________

Pet Information:

#1- Name_______________________Breed__________________

M / F {circle one} Spayed or Neutered {Circle one}

Birthday______________color_________weight______________

#2- Name_______________________Breed__________________

M / F {Circle one} Spayed or Neutered{Circle one}

Birthday______________color_________weight______________

________________________________________________________

Veterinarian Information:

Name/ Hospital___________________________________________

Address___________________________________________

Phone #_____________________Fax____________________

How did you hear about Grand Central pet station?

____________________________________________________

Pet personality profile

How long have you had your dog?_______________________

Where did you get your dog?____________________________

If adopted, do you have any information on your dogs history?

______________________________________________________

Circle all answers that describe your dogs personality-

Outgoing / verbally sensitive / timid / pushy / affectionate /

submissive / insecure or clingy / excitable / playful / gentle/

quiet or subdued / mouthy

Describe your dogs activity level- Low / Medium / High

How would you describe your dogs demeanor while riding in a car? Enjoys / Dislikes / Neutral

Does your dog normally ride in a crate while in the car?

Yes / No

Circle all situations where your dog may become unfriendly or react in a negative or agressive manner-

Grabbing collar / hugging / removing from furniture / touching while sleeping / touching mouth, tail , ears or other.

If you answered yes to any of the above , please circle the behavior / reaction that best describes your dog in the aforementioned situations- will bite / may bite / growls /

shows teeth / trembles / or moves away.

Does your dog have any noise sensitivities?_____________

Does your dog like children ?__________________________

Which flea preventative do you use?____________________

When was it last administered?_________________________

Does your dog have any health issues that would restrict his activities or movement?_______________________________

Does your dog have any allergies?______________________

Does your dog have any dietary restrictions?______________

_____________________________________________________

What does your dog do when you are not at home?________

_____________________________________________________

Are there any people your dog fears or dislikes?___________

How does your dog react to smaller dogs or puppies?______

_____________________________________________________

Has your dog ever growled or snapped at anyone who has tried to take food or toys away?_________________________

Has your dog ever bitten anyone, if so what happened,_____

_____________________________________________________

Has your dog ever climbed a fence?_____________________

Please list the feeding instructions for you dog____________

_____________________________________________________

Is there any other information you think would be helpful?

___________________________________________________

____________________________________________________

The undersigned owner hereby represents that the information provided on this interview checklist is true and correct and that no information has been omitted that may materially change "Grand Central Pet Station's" acceptance of my dog for daycare or boarding. My dog has not been exposed to Rabies, Canine cough, or other communicable diseases during any 30 day period prior to boarding or daycare, and that all vaccinations are current and will be maintained as outlined and required.

Signature-

Dog Owner ______________________________Date_________

Address______________________________________________

City________________state______________zip____________