*** INFORMATION ABOUT YOUR HOUSEHOLD ***

Please list all the human members of your household with their ages & occupations.

Name

Age (Yrs)

Occupation

Current Dog's Name

Age

Breed

Gender

Altered

Comfy with dogs?

_ Male Female

Yes _ No

_ Yes No

_ Male Female

_ Yes No

_ Yes No

Current Cat(s) Name

Age

Breed

Gender

Altered

Comfy with dogs?

  _ Male Female

_ Yes No

_ Yes No

  _ Male Female

_ Yes No

_ Yes No

Current Other Pet Types   

If you do not have a dog, have you ever owned a dog for which you were the primary caretaker?  _ Yes No

If yes, what happened to the dog?      

Will your Rescue Dog come into regular contact with any children under the age of 10?   _ Yes No

Does anyone in your house have allergies to animal hair / fur?   _ Yes No

Do you own or rent your home?      _ Own Rent

How long at current residence: 

If you rent, has your landlord provided written permission for you to have a dog? _ Yes No

Please provide your landlord’s name & phone #:   

*** INFORMATION ON THE CARE OF YOUR DOG ***

Where will your Rescue Dog be kept during the day?                              

Where will your Rescue Dog be kept at nighttime?     

How many hours per day will your dog(s) be alone (without humans) on a regular basis?      

Do you have a fenced Yard? _ Yes No

Is this fence adequate to safely contain a dog? _ Yes No

Will the dog(s) be allowed in the house?  _ Yes No

Will the dog(s) have the free run of the house?  _ Yes No

Are you willing to use a crate for your Rescue dog? _ Yes No

Will the dog(s) be kept on a runner or tied outside?  _ Yes No

Will the dog(s) be walked daily? _ Yes No

Will your dog(s) receive formal obedience training?  _ Yes No

 *** REFERENCES *** 

Who is your Veterinarian? 

Vet’s address: 

Vet’s phone number: 

If you haven’t been with this vet for your pet’s entire life, please also provide us with your previous vet’s contact information.

Please give 2 Personal References – not a relative or household member

Name

Phone number

Relationship

 *** MISCELLANEOUS QUESTIONS ***

May we visit your home prior to application approval?   _ Yes No

Are you aware that routine costs of maintaining a dog can be at least $500 a year? _ Yes No

Do you understand the state and local ordinances concerning licensing and leashing? _ Yes No

Have you sold, given away, or surrendered a pet to a shelter, pound or Humane Society?   _ Yes No

If yes, please provide details?      

Have you or any member of your family/ household been cited for animal cruelty?   _ Yes No

If yes, please provide details?    

Comments:     

Comments:     

Comments:     

Comments:     

*** AGREEMENT ***

I attest that the Terms and Conditions of Adoption as stated in the Adoption Contract have been read in full by me and I understand that this is part of the adoption process and will be enforced.  I attest that the information provided on this application is true and accurate to the best of my knowledge.  I attest that I have retained a copy of the Adoption Contract and also understand that completion and submission of this application does not guarantee adoption of a Rescue dog. If filling out the application electronically, your name below substitutes for a signature.    

 Applicant’s name:    

 Today’s Date:         M/D/YY