Date*

First Name*

Last Name*

Address*

City, State & Zip*

Home Number*

Work Number*

Cell Number*

Your email

Why do you want to adopt a Soft Coated Wheaten Terrier?*

Have you previously owned a Wheaten?*
YesNo

What other breed(s)of dogs have you owned? *

What happened to your last dog?*

Do you have other pets?*
YesNo

If yes, specify type and sex of all dogs and other pets in the home*

Do you have children?*
YesNo

If yes, please state their ages

Is someone home during the day?*
YesNo

If not home during the day, what is the longest time away?

Do you have a fenced yard?*
YesNo

If yes, how tall is the fence?

Do you own, rent, or lease your home?*
OwnRentLease

Do you intend to keep your wheaten?*
InsideOutside

Are you aware of Wheaten Grooming needs?*
YesNo

Will you obedience train the dog?*
YesNo

Are you willing to adopt a dog that needs additional training?*
YesNo

Will you accept a dog needing special medical attention?*
YesNo

Are you willing to adopt an older/senior dog?*
YesNo

Do you have a preference as to male or female?*
MaleFemaleEither

Do you currently have a family veterinarian?*
YesNo

If yes, please state Vet name and telephone number*

How far into what other states would you be willing to travel to obtain a Wheaten?*

Additional information you would like to give us*

I hereby certify that all the information contained on this Application is true and correct. I certify that my purpose in adopting a Soft Coated Wheaten Terrier is to have a family pet, and not to use for research. I understand that I will be required to sign an Adoption Contract and Ownership Agreement and a Release of Liability and Indemnification. This application will become part of those agreements by reference, and any misrepresentation in this application will constitute a breach of the Adoption Contract and Ownership Agreement.

Please agree to the statement above

I agree