Application to Adopt Application to Adopt Fields marked with an * are required HTML We sincerely hope we have an animal that fits your needs. Please fill out this questionnaire completely. It is designed to help us find you the most compatible pet with your lifestyle. Our ultimate goal is to match the right dog with the right home for the enduring happiness of both dog and owner. This is an “application” and does not guarantee you will end up with one of our pets. Name of Dog You Wish to Adopt * Field LabelWhere you saw him/her * Divider Personal Information Personal Information Adopter’s Name * Age * Email * Address * Home Phone * Cell * City * State * - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC ARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EAST ARMED FORCES AMERICA (EXCEPT CANADA) ARMED FORCES PACIFIC Zip Code * Fax Name of Complex/Community * Own * Yes No Rent * Yes No Radio List * House Condo Apartment Townhouse Live w/parents Other (explain) Other (explain) Landlord’s Name * Phone Divider HTML Employment Information Occupation * Employer Name * Phone * Address/City/State/Zip * How long there? * HTML Pet HistoryPet Information you now have in your home Type/Breed * Name * Sex * M F Spay/Neut * Yes No Age * Owned Since * Comments * Divider Type/Breed Name Sex M F Spay/Neut Yes No Age Owned Since Comments Divider Do you use Heartworm Prevention? * Yes No Brand Name * Place of purchase * Are your current pets up to date on shots? * Yes No Divider HTML Previously Owned Pet Information Type/Breed Name Sex M F Spay/Neut Yes No Age Dates Owned What happened to him/her? Divider Type/Breed Name Sex M F Spay/Neut Yes No Age Dates Owned What happened to him/her? Divider Have you ever surrendered a pet to a shelter or given one away? Yes No If yes, what were the circumstances? Divider HTML Pet Care Why are you interested in this pet? * Do you have a securely fenced-in yard? * Yes No Fence height Fence type If not, are you willing to leash walk at all times? * Yes No Number of adults in your household * children * Ages * Do you have much contact with grandchildren or neighborhood/other children in your home? * Yes No What are the working hours of the adults in the house? * Daily Weekly This dog will be alone without human companionship for about ........ hours per day. * Where will the dog be kept during the day? * At night? * Specifically, where will it be kept when left alone? * Where will it sleep? * Who will be primarily responsible for the care of the dog? * Some dogs require a special diet….is that okay with you? Yes No Does anyone in the home have any allergies? * Yes No Are you willing to take the time to work with a dog on housebreaking issues? * Yes No Knowing that some rescue pets have had little/no training, are you willing to take obedience classes? * Yes No Have you personally ever taken a basic obedience class of any kind? * Yes No Where/when * What training methods have you used in the past? * Do you believe in crate training? * Yes No Ever used it? * Yes No What will you do with the dog if you move, change housing, add on to family, or if an illness arises and you are no longer healthy enough or financially able to care for this pet? * Divider HTML Veterinarian Information Your Veterinarian is/was * Address * City/St/Zip * Phone * Divider HTML Deal BreakersPlease indicate Yes or No to identify the following circumstances that would prohibit you from keeping this pet Move out of state * Yes No Digging * Yes No Chewing * Yes No Too much hair? * Yes No Barking * Yes No New Baby * Yes No Pet grew too large * Yes No Housebreaking Issues * Yes No Kids ignore pet * Yes No Pets didn’t get along * Yes No Destructive behavior * Yes No Expensive pet bills * Yes No Family changes/new relationship * Yes No No time for pet * Yes No Move to a new place that would not allow pets * Yes No OTHER * Divider HTML Please List 2 Personal References Name * Phone * Time they’ve known you * Name * Phone * Time they’ve known you * Would you object to our visiting your home and meeting all members of your family? * Yes No Signature * Date * Printed Name * Additional Information/Comments/Questions If you are a human seeing this field, please leave it empty. Need access to Puppy Adoption Addendum? Click here