Name *

First Name

Last Name

Age(s) of people in the home *

select all that apply

Under 20 years old

20-35 years old

35-50 years old

50-65 years old

65-80 years old

Over 80 years old

Do you/your partner work? *

select all that apply

Yes - full time

Yes - part time

Yes - other

No

Are there any children living at this address? *

Yes

No

Type of property? *

House

Bungalow

Flat/Apartment

Other

Does your home have a garden? *

Yes

No

Is your garden securely fenced in? *

Yes

No

If securely fenced, how tall are your walls/fences at the lowest point?

under 4ft

4ft

5ft

6ft

Over 6ft

If rental accomodation, do you have the landlord's permission to have a dog at this address? *

Yes

No

Not applicable (you own the home)