EmailMe Form - PBRC Adoption Application

EmailMeForm

Terms of Use:
I hereby understand that Pit Bull Rescue Central makes no representations or warranties, expressed or implied, about the dogs applied for through this form. Pit Bull Rescue Central does not know the animal's temperament and is hereby absolved from any liability related to the adoption of the animal. I also understand that Pit Bull Rescue Central is not involved in the decision process and gives no guarantees, expressed or implied, of the suitability of the animal to the adopter and/or his family *
Agree
Disagree
Rescue you are applying to: *
Email of rescue you are applying to: *

Confirm
Name *
First Last
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Home Phone
### - ### - ####
Work Phone
### - ### - ####
Your Email

Confirm
How old are you? *
Occupation? *
Do you live with? *
Spouse
Parents
Alone
Roomate
How many adults 21 and over in your household? *
How many individuals 21 and under in your household? *
What are the ages of the individuals under 21? *
How far could you drive to pick up a dog? *
If needed, would you pay for or assist with shipping expenses? *
Yes
No
By checking YES you agree that the dog will not be used in any illegal activities nor be found at any time in a municipality where Pit Bull presence is illegal. *
Yes
No
By checking YES you agree that the dog is to be kept as a house pet. It shall not be sold for medical or experimental purpose, and it shall not be used for breeding. *
Yes
No
Dog(s) you are interested in adopting - Choice

Choice #!

Choice #2

Choice #3
Are you looking for a: *
Male
Female
Either
Do you prefer a: *
Adult
Puppy
Either
If you have a preference in color and weight, please describe it here:
Prefer dog to be: *
Already spay/neutered
Not spay/neutered
Doesn't matter
Additional requirements about the dog you would like to add:
Dog's living situation: *
Dog will be housepet, living inside with family
Dog will live in basement or garage
Dog will live outdoors
Dog house provided
Guard dog
Other
How many hours a day will dog be home alone? *
When home alone dog will be *
In a crate, wire cage or dog pen inside
In a kennel - Outdoor
Tied up outside on a chain
Tied up outside on a cable run
Dog will be loose in house
Dog will be loose outside
Other
How will you exercise the dog? *
Leash walks everyday
Will have cable dog run in yard
Will be free to run in fenced yard
Dog house provided
Will have supervised access to unfenced yard
Will be free to roam around, (unleashed, unsurpervised in unfenced area)
Will bring to dog park (public area where dogs can run and play together unleashed)
Other
What type of area is the home in *
Urban (inner city)
Suburban (outer city)
Rural (country)
Yard size is: *
Small
Medium
Large
Acreage
Is the yard enclosed by a fence? *
Yes
No
If so, height, length, and type of fence:
Do you live in a *
House
Apartment
Condo
Trailer
Do you own the property? *
Yes
No
If you are renting, please provide Landlord's name and phone number for verification:
Does your municipality have breed specific restrictions? *
Yes
No
If so, please describe the nature of the restrictions:
IMPORTANT: Many homeowner's insurance companies have breed blacklists which include, but are not limited to, pit bulls, American Pit Bull Terriers, American Staffordshire Terriers, Staffordshire Bull Terriers, Rottweilers, Dobermans, Akitas, American Bulldogs, Chows and wolf-hybrids and will not insure you if they reside in your home or may cancel your insurance if you add a dog of these breeds to your home. Please check your homeowner's insurance policy regarding breed discrimination BEFORE adopting a pit bull type dog. Landlords may also have these same breed restrictions due to their insurance policies.
Do you have other DOGS? *
No other dogs
One or more spayed femail
One or more neutered male
One or more UNspayed femail
One or more UNneutered male
Other
Other combinations?
Please specify breeds and ages of other dogs:
If you had other dogs in the past, please let us know their current disposition: *
Still have the dogs
Died of old age/fatal disease
Gave or sold to friends, relatives or aquaintences
Was hit by a car
Lost/Stolen
Other
Please specify what happened:
What other kind of animals do you own? *
Of all the breeds available why do you want a Pit Bull ?
Experience: Please relate any prior experience you have had with this breed:
References: Please supply the name and phone number of your current veterinarian, or the one who saw your previous pet(s), with their title identification. If you don't have a vet, please provide the name of your employer, clergyman, or anyone not related to you who can attest to your character. Vet references are preferred. * *
Additional information you would like to provide about yourself and/or the dog you would like to adopt: *

Choice #!
Choice #2
Choice #3