EmailMe Form - REFERENCE CHECK FORM

YOUR INFORMATION

Name (must match Adoption Application) *

First Last

Home Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Phone *

### - ### - ####

What time of day is it okay to call?

Cell Phone *

### - ### - ####

Email *

Occupation *

Employer *

Work Phone *

### - ### - ####

Okay to call at work? *

Yes

No

Spouse/Partner's Name

First Last

Spouse/Partner's Occupation

Spouse/Partner's Employer

VETERINARY REFERENCE

Please list contact information for your current (or most recent if you do not currently have pets) Veterinarian. BY PROVIDING THIS INFORMATION YOU AUTHORIZE IGCA RESCUE TO CONTACT YOUR VETERINARIAN AS A REFERENCE.

Veterinarian's Name *

First Last

CLINIC NAME *

CLINIC ADDRESS

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Web Site

Please list the owner name under which the animals would be found in your veterinarian's records. *

PERSONAL REFERENCES

Please list two personal references. We prefer that one reference be a neighbor. References MAY NOT be residents of the same household, spouses/significant others, or family members/relatives.

First Reference Name *

First Last

Relationship to Applicant *

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

Second Reference Name *

First Last

Relationship to Applicant *

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

EMERGENCY CONTACT

Please provide contact information for your nearest living relative or close friend, who would be able to reach you under any circumstances. Emergency contact may NOT be a person residing in the same household.

Name *

First Last

Relationship to Applicant *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

As part of our adoption process, a rescue volunteer will come out to your home to complete a home visit. *

Yes, I will participate in a home visit.

No, I do not want a home visit. I understand that my home cannot be approved for adoption without a home visit.

As part of our ongoing post-adoption followup program, we may periodically contact you for updates on your Italian Greyhound. *

Yes, I agree to provide periodic updates.

No, I do not want ongoing followup.

THANK YOU for completing your Reference Check Form!

Please remember that IGCA Rescue is staffed entirely with unpaid volunteers. Please be both patient and persistent as you go through an adoption process.