DOGTORS APPLICATION FORM

LAST_____________________________FIRST___________________M.I.____ 

ADDRESS________________________________________________________

CITY_____________________COUNTY________STATE_______ZIP________

PHONE____________________ OTHER PHONE________________________

E-MAIL_______________________________  AGE_____  D.O.B.___________

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PET’S NAME_____________________________  M__   F__     AGE_________

BREED/SPECIES_____________________________________  Weight______

Is this your pet? _____ How long have you had your pet? __________________

(If this is NOT your own personal pet OR there is information different than above, please answer the question below provide owner information on back)

If above was answered NO, How long have you known or worked with this animal?______________

Has this pet ever displayed any aggressive behavior? ________  (If YES, please describe on the back)

Are you covered by homeowner’s, renter’s or umbrella liability Insurance? _____

Who is your primary Veterinarian?_____________________________________

Who should we contact in case of an emergency? ________________________

I understand that any information I have provided is strictly for DOGTORS records and will not be shared, sold, or otherwise given to any individual or group.
I also understand that DOGTORS does background checks on all the animals with the vets and with animal law enforcement for bite or aggression history. 
I also guarantee by my signature that I have been honest in all the above information provided and will be liability responsible for any falsification. 

_____________________________	    ________________
Signature of Student				Date

____________________________			  Send to:     DOGTORS AAT
Signature of Parent / Legal Guardian				         4033 Spfld-Xenia Rd.
	                                                                                            Springfield, OH 45506