Please complete the form below.
Applicant Name
*
City
*
State
Reference Checker Name
Ref Checker's Phone Number
Ref Checker Email
Interviewer Name
Vet/Clinic Name:
Phone Number
Years known:
Number of pets owned in past five years?
Are pets spayed/neutered?
Are pets up to date on shots?
Would vet/clinic recommend that SCBR place a rescue dog with the applicant?
Additional Comments?