Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Phone - Cell
(###)
###
####
Email
Best Time to Reach You?
Please Select
AM
PM
What type of housing do you live in?
Please Select
Townhouse
Apt/Condo
Single Family Home
Do you own or rent?
Please Select
Own
Rent
If you rent, does your landlord permit dogs?
Please Select
Yes
No
N/A
Not Sure
If you rent, is there a weight/size limit on allowable dogs?
Please Select
Yes
No
Not Sure
If yes, what is the weight/size limit?
If you rent, please provide your landlord's name and contact information for verification of requirements:
First Name
Last Name
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you have stairs in your home?
Please Select
Yes
No
If Yes. How many
Do you have a fenced in yard?
Please Select
Yes
No
If yes, please describe your fence (height, type etc):
If no, do you agree to keep the basset on a leash when outdoors?
Please Select
Yes
No
Are you willing to have a volunteer from BHROM visit your home prior to adoption?
Please Select
Yes
No
How many adults live in your household?
Select One
1
2
3
4
5
6
7
8
9
How many children live in your household?
Select One
0
1
2
3
4
5
6
7
8
9
10
If there are children in the household, what are their ages?
Are there other children who visit frequently (i.e. grandkids, babysitting)
Please Select
Yes
No
If yes, what are the visiting children's ages?
Describe the temperament of the dog(s) you currently own.
Please Select
Dominant
Submissive
Both
DO NOT HAVE A DOG
Describe the activity level of the dog(s) you currently own.
Please Select
Docile
Active
Both
DO NOT HAVE A DOG
Do you give heartworm preventative to your dog(s) on a monthly basis?
Please Select
Yes
No
Does anyone in the household have dog allergies?
Please Select
Yes
No
How close is your nearest neighbor?
Vet's Name
Vet's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Vet's Phone
(###)
###
####
What pet name and last name are your current vet records under?
Why do you want to adopt a basset?
Will this be your first dog/basset as an adult?
Please Select
First Dog & First Basset
Have had other dogs - This will be my first Basset
No - Have had dogs & Bassets as an adult
Have you ever adopted a dog from a rescue organization or shelter?
Please Select
Yes
No
If you have adopted a dog from a rescue organization or shelter - what is their name?
Have you ever had to give up a dog?
Please Select
Yes
No
If you have given up a dog please explain
How do other family members feel about adopting a basset?
Which family member will be the basset's primary caregiver?
How many hours per day will the basset be left alone?
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
Where will the basset be kept during the day?
Where will the basset be kept during the night?
Are you willing to provide the required heartworm preventative on a monthly basis?
Please Select
Yes
No
Are you willing to provide BHROM with follow up reports?
Please Select
Yes
No
Do you agree to return your basset to BHROM if you are unable to keep it?
Please Select
Yes
No
Would you prefer a male or female basset?
Please Select
Male
Female
No preference
What age basset do you prefer? (Select all the age(s) that apply.)
Please Select
Age 1 - 3
Age 3 -7
Age 5 - 10
Senior of any age
The age doesn't matter
What specific traits are you looking for in a basset that would make him/her the right match for your family?
Have you ever taken a dog to obedience training?
Please Select
Yes
No
If you've taken them to training, where did you go?
Are you willing to take your basset to obedience training if necessary?
Please Select
Yes
No
Are you willing to house train your basset, if necessary?
Please Select
Yes
No
Are you willing to crate train your basset?
Please Select
Yes
No
How were you referred to BHROM
If you have other comments or have a specific basset on our website you are interested in, please indicate below
First Pet - Name
First Pet - Dog (Breed), cat, bird, other
First Pet - AGE (yr/Mos)
First Pet - Time owned
First Pet - Sex
Please Select
M
F
First Pet - Spay/ Neuter
Please Select
Yes
No
First Pet - Date of last inoculations for Rabies
MM
DD
YYYY
First Pet - Date of last inoculations for DHLPP
MM
DD
YYYY
First Pet - Date of last inoculations for Bordatella
MM
DD
YYYY
First Pet - Date of last heartworm test
MM
DD
YYYY
Second Pet - Name
Second Pet - Dog (Breed), cat, bird, other
Second Pet - AGE (yr/Mos)
Second Pet - Time owned
Second Pet - Sex
Please Select
M
F
Second Pet - Spay/ Neuter
Please Select
Yes
No
Second Pet - Date of last inoculations for Rabies
MM
DD
YYYY
Second Pet - Date of last inoculations for DHLPP
MM
DD
YYYY
Second Pet - Date of last inoculations for Bordatella
MM
DD
YYYY
Second Pet - Date of last heartworm test
MM
DD
YYYY
Third Pet – Name
Third Pet - Dog (Breed), cat, bird, other
Third Pet - AGE (yr/Mos)
Third Pet - Time owned
Third Pet – Sex
Please Select
M
F
Third Pet - Spay/ Neuter
Please Select
Yes
No
Third Pet - Date of last inoculations for Rabies
MM
DD
YYYY
Third Pet - Date of last inoculations for DHLPP
MM
DD
YYYY
Third Pet - Date of last inoculations for Bordatella
MM
DD
YYYY
Third Pet - Date of last heartworm test
MM
DD
YYYY
Fourth Pet – Name
Fourth Pet - Dog (Breed), cat, bird, other
Fourth Pet - AGE (yr/Mos)
Fourth Pet - Time owned
Fourth Pet – Sex
Please Select
M
F
Fourth Pet - Spay/ Neuter
Please Select
Yes
No
Fourth Pet - Date of last inoculations for Rabies
MM
DD
YYYY
Fourth Pet - Date of last inoculations for DHLPP
MM
DD
YYYY
Fourth Pet - Date of last inoculations for Bordatella
MM
DD
YYYY
Fourth Pet - Date of last heartworm test
MM
DD
YYYY
Fifth Pet – Name
Fifth Pet - Dog (Breed), cat, bird, other
Fifth Pet - AGE (yr/Mos)
Fifth Pet - Time owned
Fifth Pet – Sex
Please Select
M
F
Fifth Pet - Spay/ Neuter
Please Select
Yes
No
Fifth Pet - Date of last inoculations for Rabies
MM
DD
YYYY
Fifth Pet - Date of last inoculations for DHLPP
MM
DD
YYYY
Fifth Pet - Date of last inoculations for Bordatella
MM
DD
YYYY
Fifth Pet - Date of last heartworm test
MM
DD
YYYY
