C.A.R.E

Applicants First Name *

Applicants Last name *

Applicants Address *

City/ State/ Zip Code *

Phonenumber *

Applicants Email Address *

*

Home Visit Acknowledgment: I understand and acknowledge that a home visit by M.C.A.S staff may be required as part of the application review to verify placement of the dog house.

Number of dogs needing a dog house? *

Dogs name? *

Breeds *

Dogs Ages *

Approximate size and weight *

Sex of dog (s)? *

Has your dog (s) been altered?

Is dog primarily kept outside? *

Does the dog currently have shelter? *

If yes, Please describe the current shelter being used by the dog(s).

Is the dog provided fresh water and food daily? *

Are you the legal owner/caregiver for the dog(s) listed. *

The dogs reside at the above listed address. *

I agree to use the provided dog house for the listed dog(s) only. *

I understand the dog house must remain with the property and dog(s) *

I agree to allow a representative to verify placement if required. *

I understand and agree that if the dog(s) listed are rehomed, surrendered, transfered or deceased that Montgomery County Animal Shelter must be notified so the dog house can be retrieved. *

I certify that the information provided above is true and accurate to the best of my knowledge. I understand that submitting this application does not guarantee approval and that availability is limited. *

OFFICE USE ONLY *