Eligibility  Interview  Checklist- application

Owners Name_____________________________Date__________
Home Ph#______________Cell Ph#_________________________
Employer________________Work Ph#_______________________
Emergency person to contact if we cannot reach you:
Pet Information:
#1- Name_______________________Breed__________________
M / F {circle one}      Spayed or Neutered {Circle one}
#2- Name_______________________Breed__________________
M / F {Circle one}     Spayed or Neutered{Circle one}
Veterinarian Information:
Name/ Hospital___________________________________________
Phone #_____________________Fax____________________
How did you hear about Grand Central pet station?
Pet personality profile
How long have you had your dog?_______________________
Where did you get your dog?____________________________
If adopted, do you have any information on your dogs history?
Circle all answers that describe your dogs personality-
Outgoing /  verbally sensitive / timid / pushy / affectionate /
submissive / insecure or clingy /  excitable /  playful / gentle/
quiet or subdued / mouthy
Describe your dogs activity level- Low / Medium / High
How would you describe your dogs demeanor while riding in a car? Enjoys / Dislikes / Neutral
Does your dog normally ride in a crate while in the car?
Yes / No
Circle all situations where your dog may become unfriendly or react in a  negative or agressive manner-
Grabbing collar / hugging / removing from furniture / touching while sleeping / touching  mouth, tail , ears  or other.
If you answered yes to any of the above , please circle the behavior / reaction that best describes your dog in the aforementioned situations- will bite / may bite / growls /
shows teeth / trembles / or moves away.
Does your dog have any noise sensitivities?_____________
Does your dog like children ?__________________________
Which flea preventative do you use?____________________
When was it last administered?_________________________
Does your dog have any health issues that would restrict his activities or movement?_______________________________
Does your dog have any allergies?______________________
Does your dog have any dietary restrictions?______________
What does your dog do when you are not at home?________
Are there any people your dog fears or dislikes?___________
How does your dog react to smaller dogs or puppies?______
Has your dog ever growled or snapped at anyone who has tried to take food or toys away?_________________________
Has your dog ever bitten anyone, if so what happened,_____
Has your dog ever climbed a fence?_____________________
Please list the feeding instructions for you dog____________
Is there any other information you think would be helpful?
The undersigned owner hereby represents that the information provided on this interview checklist is true and correct  and that no information has been omitted that may materially change "Grand Central Pet Station's" acceptance of my dog for daycare or boarding. My dog has not been exposed to Rabies, Canine cough, or other communicable diseases during any 30 day period  prior to boarding or daycare, and that all vaccinations are current and will be maintained as outlined and required.
Dog Owner ______________________________Date_________