Name of dog you are interested in?

Why you are interested in a Rescue Dog?

Your Information:

Applicant's Name and Age:

Spouse's Name and Age:

Address:

City, State: Zip:

Home Phone:

Work Phone:

Email Address:

Name and Ages of all who live in household:

Do you/spouse work outside the home? yes no

How many hours are you gone?

Is someone home during the day? yes no

If No, how many hours will the dog be left alone?

Where will he/she stay when you're at work?

Is everyone in your household in agreement on adopting a rescue dog? yes no

Visiting children/grandchildren and AGES:

Your Home:

Do you live in a House, Condo, Apartment, or Mobile Home?

Do you Rent, Own or live with Parents?

If you Rent, Landlord's Name:

Landlord's Address:

City, State: Zip:

Landlord's Phone:

Rental Contract Required

Does your home have a Yard ? yes no

Is there a Fence? yes no

Type and Height of Fence:

Pet Care:

Will the dog be kept on leash if not in fenced area? yes no

When you travel where / how will the dog be cared for?

Undesired traits in a dog:

What would you do if the dog got a chronic illness ?

In the event of an untimely death or chronic illness of you or spouse, what would happen to the dog?

Are your pet's current on all vaccinations? yes no

Are your pet's Spayed / Neutered? yes no

Are your pets on Heartworm Preventitive? yes no

Are your pets on Flea Treatment? yes no

Have you ever given away, sold, surrendered, euthanized or "gotten rid" of a pet? yes no

If Yes, Explain:

Do you have any other pets? (Breed, Age, Sex)

References:

Veterinarian Name and Phone:

Name that animals are under at Vets Office: (Pet and Owner name)

If you do not currently have, or have never had a vet, please provide THREE (3) References NOT RELATED TO YOU: (Include Name, Phone, Relationship)

Comments:

Additional comments you would like to make to help us better evaluate your application for adoption: