Puppy Raiser Application

ACTS - Assistance Canine Training Services
2928 East Conway Road
Center Conway, NH 03813
603-383-2073

IMPORTANT INSTRUCTIONS: Please read carefully

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

Date*

Date

Name*

First NameLast Name

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Shipping Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone*

Area CodePhone Number

Home Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Email*

example@example.com

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

Are you interested in applying to be a short term puppy raiser (six months) or long term puppy raiser (approx. 18-24 months)?

Dog Training Experience

Have you ever personally obedience trained a dog?*

YesNo

Have you ever taken any dog training classes?*

YesNo

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

YesNo

Please comment on the above dog training questions.*

Household Occupants

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

Name

First NameLast Name

Age

Relationship

Name

First NameLast Name

Age

Relationship

Name

First NameLast Name

Age

Relationship

Name

First NameLast Name

Age

Relationship

Name

First NameLast Name

Age

Relationship

Is everyone in the family in agreement about puppy raising for ACTS?*

YesNo

Is anyone in the household allergic to dogs?*

YesNo

Please talk about any preferences regarding breed or sex that you may have and why. ACTS 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?*

YesNoNo 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 ACTS*

Are you a smoker?

YesNo

Are there any other smokers in the household*

NoYes, one otherYes, more than one other

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

References

First Reference

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Relationship to applicant*

Second Reference

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Relationship to Applicant*

Third Reference

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Relationship to Applicant*

Are you willing to follow the rules and regulations for puppy raising as outlined by ACTS?*

Yes

ACTS requires volunteers to carry personal auto liability insurance on all personal vehicles that transport dogs. Do you carry personal auto liability insurance?

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 ACTS appropriately as outlined by their policies and procedures?*

Yes

I acknowledge that by submitting my name and signing below, that all the above information is accurate and that I fully understand all the conditions presented above.

Name*

First NameLast Name

Please Sign and Submit*