Please provide the following contact information:                               

First Name
Last Name
Street Address
Address (cont.)
City
State
Zip/Postal Code
Home Phone
Work Phone
E-mail Address
Drivers License #
Date of Birth
Employer Name
Employer Address
Spouse's Name
Spouse's Employer

If you are interested in a particular dog, please type name here: 

I live in a :   Select House Apartment Duplex Condominium Mobile Home Other

 Number of Adults in household:

Number of Children in household:   

    Children's Ages: 

 Do ALL of the adults in the household consent to this adoption?    yes    no

 Are you or your spouse a student?    yes    no

 Do you or your spouse travel frequently?      yes    no

    If yes, how often?

 What arrangements will you make for your pet when you need to travel?

 Does ANYONE living in your house have allergies?     yes    no

    Check all that apply:    cats  dogs  other

 Does anyone living in your house have asthma?    yes    no

 Do you have a fenced yard?     yes    no

    Type:   Select Wood Fence Other  

     Height:  feet

 How long have you lived at current address? 

 Do you own your home?    yes    no

 Do you plan to move in the next 12 months?      yes    no     

    If yes, where: 

 

If you rent your home:

    Does your landlord allow pets?    yes    no

    Is a pet deposit required?    yes    no

         Deposit amount per pet?    $     

    Is there a size/weight limit?    yes    no

         Limit: 

    Can proof of deposit be obtained from your landlord?    yes    no

    Name of Apartment Complex or Landlord:                                   

    Phone number of Apartment Complex or Landlord (required):   

 

 

 This pet will be kept:   Select Mostly indoors Mostly outdoors Always indoors Always outdoors

 If applying for a dog, do you plan to chain it in the yard?    yes    no

 How long will the pet be left home alone during the day?    hours per day days per week

 Where will the pet be kept while your are away from home?   

 Where will the pet sleep at night?   

 Do you plan on enrolling this pet in an obedience class?    yes    no

 Are you willing/able to purchase and use a cage/crate if needed or advised?    yes    no

 Can you keep this pet away from the other pets in the house for one week?    yes    no    no other pets

 Who are you getting this animal for?    Select Myself My family My children Friend Family Member Other

 Do you want this pet to be spayed/neutered?    yes    no

 Why do you want to adopt a Boston Terrier?

 Do you plan on having children?    yes    no

 Is appearance important to you?    yes    no

Is size important to you?    yes    no

Are you willing to accept a Boston Terrier with health problems?    yes    no

Are you willing to accept a Boston with behavior problems?    yes    no

How much are you willing to spend on a rescue dog per year?  $

 

PET OWNERSHIP HISTORY

Have you ever adopted from a rescue group or shelter?    yes    no

     If yes, who did you adopt from:    

    When?   

 Have you ever had to give an animal up for adoption or gotten rid of an animal for any reason?    yes    no

    If so, why? 

    What did you do with the animal? 

 Are all the pets in your household current on their shots?    yes    no    no pets

    What is the date of last vaccinations? 

 Are all your dogs on Heartworm preventive?    yes    no     no dogs

    What kind of Heartworm preventive do you use? 

 Have any pets in your household been diagnosed with an infectious disease or condition in the last 6 months?    yes    no

    If so, what disease/condition? 

 Do any pets in your household have, or tested positive for, the following diseases or conditions?

    Heartworms    yes    no

    Distemper      yes    no     

    Parvovirus    yes    no

 Name of your veterinarian or clinic: 

 Address: 

 Phone #: 

Total number of pets currently owned:

    dogs    cats    other

Total number of pets NOT currently owned, but owned within the last five years:

      dogs    cats    other    

What happened to them? 

 

Please list all pets currently owned or owned within the last five years:

   1.  Pet's Name:   

        Pet Species:    dog    cat    other

        Breed:     

        Sex:    male    female 

        Age (if currently owned): 

        Length of ownership:    

        Do you own the pet now?    yes    no   

            If no, what happened to it? 

        Was/Is it spayed/neutered?    yes    no   

            If no, why not? 

         If the pet was a cat, was it declawed?    yes    no

        This pet was kept: Select Mostly Inside Mostly Outside Always Inside Always Outside

 

   2.  Pet's Name:   

        Pet Species:    dog    cat    other

        Breed:     

        Sex:    male    female 

        Age (if currently owned): 

        Length of ownership:    

        Do you own the pet now?    yes    no   

            If no, what happened to it? 

        Was/Is it spayed/neutered?    yes    no   

            If no, why not? 

         If the pet was a cat, was it declawed?    yes    no

        This pet was kept: Select Mostly Inside Mostly Outside Always Inside Always Outside

 

   

    3. Pet's Name:   

        Pet Species:    dog    cat    other

        Breed:     

        Sex:    male    female 

        Age (if currently owned): 

        Length of ownership:    

        Do you own the pet now?    yes    no   

            If no, what happened to it? 

        Was/Is it spayed/neutered?    yes    no   

            If no, why not? 

         If the pet was a cat, was it declawed?    yes    no

        This pet was kept: Select Mostly Inside Mostly Outside Always Inside Always Outside

 

 

        Please list above information for any other pets in the box below:

   

 

 

 

 

I confirm that all the information in this application is correct and complete to the best of my knowledge.  In addition, I agree to return the dog to the Kentucky/Tennessee Boston Terrier Rescue if I am unable to keep or care properly for the dog for any reason.  Typing your name in the box below is equivalent to your handwritten signature.

 

    Signature X:   

    Date: