Puppy Raiser ApplicationAssistance Canine Training ServicesPO Box 52North Conway, NH 03860(603)383-2073 Date * MM DD YYYY Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone * (###) ### #### Home Phone (###) ### #### Work Phone (###) ### #### Email * What name do you prefer we use for correspondence and certificates? * Are you applying to be a short term puppy raiser (six months) or a long term puppy raiser (~16 months)? * Short Term Puppy Raiser Long Term Puppy Raiser 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. Household Member #1 First Name Last Name Age Relationship Household Member #2 First Name Last Name Age Relationship Household Member #3 First Name Last Name Age Relationship Household Member #4 First Name Last Name Age Relationship Household Member #5 First Name Last Name Age Relationship If there are any additional household members, please list below. 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 comment on any preferences regarding breed or sex that you may have and why. A.C.T.S. is willing to work with puppy raiser preference but please keep in mind that specific requests can potentially delay the placement process. * Please provide the species, name, age, sex, and spay/neuter status of all dogs in your household. * 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 or rent 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 raisers for A.C.T.S. * Do you smoke? * Yes No Are there any other smokers in the household? * No Yes, One Yes, More Than One If there are smokers in the household, do they smoke in the house or in the car? Please explain. * References Reference #1 Name * First Name Last Name Phone Number * (###) ### #### Email * Relationship to Applicant * Reference #2 Name * First Name Last Name Phone Number * (###) ### #### Email * Relationship to Applicant * Reference #3 Name * First Name Last Name Phone Number * (###) ### #### Email * 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 emotionally prepared to handle the separation when your A.C.T.S. puppy is ready to leave you for its final training? * Yes Are you willing to represent A.C.T.S> appropriately as outlines by their policies and procedures? * Yes I acknowledge that by entering my name below and submitting this application, that all the above information is accurate. Name * First Name Last Name When you click the SUBMIT button, the final version of this form will be sent to A.C.T.S. Thank you!
