First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
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Email*

Home Phone

Cell Phone

Alt Email

What is the name and address of the family you are referring? (Your identity will be kept completely confidential.) *

Please describe, in as much detail as possible, the living conditions in which this dog lives on a daily basis. Describe the dog, the area of living space, housing, etc.*

How many dogs are living on this property currently?*