Puppy Raiser Application

Assistance Canine Training Services
PO Box 52
North Conway, NH 03860
781-856-0055

IMPORTANT INSTRUCTIONS: Please read carefully

Please use your TAB key to move on to the next entry box.

You must fill out this entire form in one session. If you leave your form will NOT be saved.

Date *

Date

Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone *

Area Code Phone Number

Home Phone

Area Code Phone Number

Work Phone

Area Code Phone Number

Email *

example@example.com

What name do you prefer we use for correspondence and certificates? *

Dog Training Experience

Have you ever personally obedience trained a dog? *

Yes No

Have you ever taken any dog training classes? *

Yes No

Have you ever had the primary responsibility of raising a puppy? *

Yes No

Please comment on the above dog training questions. *

Household Occupants

Please list the names, ages, and relationships of all household members.

Name

First Name Last Name

Age

Relationship

Name

First Name Last Name

Age

Relationship

Name

First Name Last Name

Age

Relationship

Name

First Name Last Name

Age

Relationship

Name

First Name Last Name

Age

Relationship

Is everyone in the family in agreement about puppy raising for A.C.T..S.? *

Yes No

Is anyone in the household allergic to dogs? *

Yes No

Please talk about any preferences regarding breed or sex that you may have and why. A.C.T.S. is willing to work with puppy raiser preferences but please keep in mind that specific requests can potentially delay the placement process. *

Please give us some information about the dogs you have in your home.

Species

Name

Age

M/F

Neutered?

Do all your dogs live inside? *

Yes No No Other Dogs

Please list any other household pets you have. *

Please list any outdoor animals you have. *

Please give us your history of dog ownership. Include what kinds of dogs, what became of them, obedience training completed, and any other pertinent information. If you were actively involved with any childhood dogs, please include them as well. *

If you work outside the home, will the puppy be able to come to work with you? *

How many hours each day will the puppy be left alone? *

Where will the puppy be kept when you aren't home? *

Do you have a fenced in yard? *

Do you own your home? *

How soon can you commit to raising a puppy? *

What is the name, address, and phone number of the veterinary hospital you currently use? *

Please tell us why you would like to be a puppy raiser for A.C.T.S. *

Are you a smoker?

Yes No

Are there any other smokers in the household *

No Yes, one other Yes, more than one other

If there are smokers in the household, do they smoke in the house or in the car? Please explain.

References

Your references should help us decide if you have the character we require to receie one of our dogs. You should select people who are NOT your immediate family. References who can specifically speak to your character, your previous volunteer experience, your willingness to learn and take on a challenge, your ability to fullfill commitment, or your abilities as a dog owner are particularly helpful.

First Reference

Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Email *

example@example.com

Relationship to applicant *

Second Reference

Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Email *

example@example.com

Relationship to Applicant *

Third Reference

Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Email *

example@example.com

Relationship to Applicant *

Are you willing to follow the rules and regulations for puppy raising as outlined by A.C.T.S.? *

Yes

Are you willing to attend the required practice sessions? *

Yes

Do you feel you are emotionally prepared to handle the separation when the puppy is ready to leave you for its final training? *

Yes

Are you willing to represent A.C.T.S. appropriately as outlined by their policies and procedures? *

Yes

I certify that all the above information is, to the best of my knowledge, accurate *

Yes

Name *

First Name Last Name