First Name *

Last Name *

Email *

City *

Home Phone

Other Phone

Other Phone Type Select Cell Work Other

Are you the owner of this dog? Yes No *

Does anyone else have an ownership interest in this dog? Yes No *

If yes, who?

Does the above grant their permission for you to place this dog for adoption? Yes No

Dog's Name *

Gender Male Female *

Breed Select Shiba Inu Jindo Shiba Mix Jindo Mix Other *

If mix or other, please describe

Dog's age or DOB *

Color Select Red Sesame Black & Tan Cream Pinto Brindle Other *

Height at shoulder *

Weight *

Spayed/Neutered? Yes No *

Up to date on vaccinations? Yes No *

When was the last set of vaccinations given? *

If the dog is not UTD, what vaccinations are needed?

Microchipped? Yes No *

If yes, what type? Avid Home Again Other

Microchip Number

Where would you consider placing your dog? *

Contact email for bio *

Contact phone number for bio (optional)

In the following space, write a bio about your dog. This bio will appear in the courtesy listing on SIRA’s website. Include as much information about your dog’s behavior, temperament, likes, and dislikes as possible. Also include information about the adoption fee you will charge. *