Support NHS

*1.

Question - Required - Name(s) of Diamond Dog(s) that you are interested in:

(Maximum response 255 chars, approx. 5 rows of text)

2.

Applicant information

*

Name:

First Required	Last Required

*

Email: Required

*

Street 1: Required

*

City/State/ZIP:

City Required	State Required	ZIP Required

*

Phone Number: Required

*

Date of Birth: Required

Date of Birth:

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

Keep me logged in. What's this?

*3.

Question - Required - Best way for us to contact you regarding this animal?

(Maximum response 255 chars, approx. 5 rows of text)

*4.

Question - 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.

Question - 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.

Question - 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.

Question - 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.

Question - Required - How many adults live in your home? Number of adults and ages.:

(Maximum response 255 chars, approx. 5 rows of text)

*9.

Question - Required - How many children live in your home? Number of children and ages:

(Maximum response 255 chars, approx. 5 rows of text)

*10.

Question - 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.

Question - Required - Have you owned or have experience with fearful dogs? If yes, please explain.

(Maximum response 255 chars, approx. 5 rows of text)

*12.

Question - 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.

Question - 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.

Question - Required - What traits are you looking for in a dog?

(Maximum response 255 chars, approx. 5 rows of text)

*15.

Question - 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.

Question - 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.

How did you hear about the dog(s) you are interested in?

(Select one of the available choices or enter a different value.)
Question - Required -

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