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Diamond Dog Survey

1. Field Is Required Name(s) of Diamond Dog(s) that you are interested in: (Maximum response 255 chars, approx. 5 rows of text)

2. Applicant information

Field Is Required First

Field Is Required Last

Field Is Required Date of Birth:

Field Is Required Street 1:

Field Is Required City/Town:

Field Is Required State / Province:

Field Is Required ZIP / Postal Code:

Field Is Required Email:

Field Is Required Phone Number:

Yes, I would like to receive e-mail from Nebraska Humane Society

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3. Field Is Required Best way for us to contact you regarding this animal? (Maximum response 255 chars, approx. 5 rows of text)

4. Field Is Required Do you currently have any pets? Please list species, breed, sex, age and if they are spayed/neutered. (Maximum response 255 chars, approx. 5 rows of text)

5. Field Is Required Do you live in an apartment or home? Do you rent or own your home? (Maximum response 255 chars, approx. 5 rows of text)

6. Field Is Required If you rent, please provide the name of your housing complex and your landlord's contact information. If not a renter, please enter N/A.

7. Field Is Required Does your home have a fenced in yard? If so, what type of fence and how high is it? (Maximum response 255 chars, approx. 5 rows of text)

8. Field Is Required How many adults live in your home? Number of adults and ages.: (Maximum response 255 chars, approx. 5 rows of text)

9. Field Is Required How many children live in your home? Number of children and ages: (Maximum response 255 chars, approx. 5 rows of text)

10. Field Is Required Do you have frequent visitors in your home? Adults or children? If they are children, please list their ages and how often. (Maximum response 255 chars, approx. 5 rows of text)

11. Field Is Required Have you owned or have experience with fearful dogs? If yes, please explain. (Maximum response 255 chars, approx. 5 rows of text)

12. Field Is Required Have you had experience with unruly (jumps on people or gets mouthy) dogs? If yes, please explain. (Maximum response 255 chars, approx. 5 rows of text)

13. Field Is Required Have you had experience with large dogs and/or small dogs? If yes, please explain (Maximum response 255 chars, approx. 5 rows of text)

14. Field Is Required What traits are you looking for in a dog? (Maximum response 255 chars, approx. 5 rows of text)

15. Field Is Required What days and times are you available to schedule an appointment to come meet the dog? (Maximum response 255 chars, approx. 5 rows of text)

16. Field Is Required We understand the decision making process can take time but with that in mind, when would you be able to take the dog home with you? (Please include any upcoming trips or moves.)

17. Field Is Required How did you hear about the dog(s) you are interested in? (Select one of the available choices or enter a different value.) How did you hear about the dog(s) you are interested in? Click this to indicate that you will select an existing value. Tab to next input." How did you hear about the dog(s) you are interested in? How did you hear about the dog(s) you are interested in? Click this to indicate that you will enter a new value. Tab to next input." How did you hear about the dog(s) you are interested in? Provide your answer here

Diamond Dog Survey

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