If you’re interested in giving one of our Jacks a forever home, please fill out this application. We’ll be in touch with you as soon as we can.

Name

Street Address

City

State

Zip

Email

Phone

When's the best time to call?

What's your occupation?

In what type of dwelling do you live?

House Apartment Trailer

Please list the number of adults and children living with you, and their ages.

If you rent your home, do you have your landlord's permission to keep a dog?

Yes No Not Applicable

What gender of dog would you prefer?

Male Female Doesn't Matter

What age dog would you prefer?

Puppy Adult Rescue

How long have you lived at your current address?

Do you have a fenced yard suitable for a dog?

Yes No

Do you own a dog crate?

Yes No

Where will the dog sleep?

Where will this dog be primarily kept?

Indoors Outdoors

How many hours a day will the dog be left alone?

Please list the breeds and ages of other dogs or large animals that you currently own. Also, are these dogs spayed or neutered?

Have you ever owned a Jack Russell Terrier before?

Yes No

What activities do you plan to do with this dog?

Do you have a current veterinarian? If yes, please provide their name and contact information so we may forward any medical records.

Do you have any questions or comments?

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