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Applicant Information
Prospective Adopter's Name*:	First	Last
Address:	Address Line 1
	Address Line 2
	AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY City State Zip Code
Veterinarian's Name:	First	Last
Hospital Name:
Email*:
Telephone:
Veterinarian's Comments (Note: Information is treated with complete confidentiality)
List current and/or former pet(s) under your care:
How long have you cared for this client's pets?:
Does this client provide consistent and timely care for all of his/her companion animals?:
Have vaccinations on all pets been kept current?:
Have the client's dog(s) been heartworm tested and maintained on heartworm preventive?:
Do you feel this client will provide a safe and nurturing home for an adopted Golden Retriever?:
Please add any other comments that would be helpful in evaluating this applicant's ability to ensure appropriate care for an adopted dog:
Veterinarian's Signature
Date:	/ / MM   DD   YYYY