Contact Information:
Name:	Date:
Address:
City:	State:   Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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 Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon   Zip:
Day Phone:	Evening Phone:
Email:
Pet Information:
Name of dog  you are interested in:

If this dog is no longer available, would you consider adopting a different dog through Rose's Rescue:     Yes   No

Do you own or rent:     Own   Rent        Years at current residence            Occupation

I authorize the landlord, if any, and their agents to release to Rose's Rescue any information in my rental agreement that pertains to pet owning and keeping.

I accept the above terms:     Yes   No

Number of adults in household:    Number of children:    Ages:

Who will be the primary caretaker of the animal:

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What pets are currently in your household?
TYPE	NAME	SPAYED NEUTERED?	KEPT WHERE?	AGE	YEARS HAD?
DogCat		YesNo	InOut
DogCat		YesNo	InOut
List your previous pets and describe why you no longer have them.
TYPE	NAME	SPAYED NEUTERED?	KEPT WHERE?	AGE	YEARS HAD?
DogCat		YesNo	InOut
Explanation:
DogCat		YesNo	InOut
Explanation:
Veterinarian:  (Info required to process application)			Phone Number:

I authorize the veterinarian listed above and their agents to release to RosesRescue any information pertinent to evaluating my history of pet ownership, if any.
I accept the above terms:     Yes   No
What specific traits are you looking for in a dog (i.e. crate trained, good with other dogs/cats, etc.):
Are you familiar with your local city regulations requiring pets to be licensed every year:     Yes   No
How may hours per day will this pet spend alone:    Why:
Where will you keep your pet at night:
Where will you keep your pet when you are not at home:
How will you confine your pet outdoors (check all that apply):
Fence, type and height	Kennel Run	Patio	Garage
Leash	Chain/Tie out/Runner	Other :
What will you do if your pet is destructive (digs, chews, etc.):
How would you describe your home activitiy level....average, busy, quiet:
What behavior(s) would cause this adoption to fail:
Do you know you may have to discipline and/or housetrain your pet, which may require time and patience. Are you willing to commit to any necessary training:     Yes   No
Will you take your pet to a veterinarian within 14 days of adoption, and regularly thereafter?    Yes   No
Would you object to a follow-up call/visit from Roses Rescue:     Yes   No Additional Comments:
It is my intention to integrate any animal I may adopt into my home and life as a pet and companion. I understand that adoption entails a commitment to provide responsibly for the pet's needs for the rest of its life. I am over age 18 and I am ready to make this commitment. I certify that the above information is true. False information will be cause for denial of this application. Roses Rescue reserves the right to deny any adoption for the sake of the animal's welfare. All completed applications are the property of Roses Rescue and will be retained in its files.
I accept the above terms:     Yes   No