EmailMe Form - SIMPLY SOUTHERN RESCUE ADOPTION APPLICATION

Date Time

MM / DD / YYYY

Name

First Last

Phone

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

Address

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

Email

Dog you are interested in

If you rent, does your rental agreement allow you to have a dog?

Note: A letter from your landlord may be required prior to adoption

Yes

No

What type of neighborhood do you live in?

Urban

Suburban

Rural

Do you have a fenced yard?

Yes

No

Partial

Do you work at home?

Yes

No

Do children live in the home?

Yes

No

If yes, what are their ages?

Typical work day schedule at your house?

Why are you interested in adopting a dog?

What is your occupation?

Is everyone in the household in agreement about adopting a dog?

Yes

No

What lifestyle changes do you expect in the next 12 months? Children, moving,retirement, job change, etc...

What lifestyle changes do you expect in the next 5 years?

Do you have any other pets?

Yes

No

Please list the names, ages, and types of other pets in the house

If you currently have a dog, describe it's behavior towards other dogs and humans

What form of discipline do you use for your pets?

Have you ever surrendered an animal to a shelter or given one away for any reason?

Yes

No

Will you have your dog on heart worm prevention?

Yes

No

Are you financially able to provide good quality food and vet care?

Yes

No

May need help

What age dog do you prefer?

Would you be willing to adopt a "special needs" dog or senior?

Yes

No

Possibly

Where will the dog stay while you are away from the home?

Where will the dog sleep?

Where will the dog stay when you go on vacation?

How much time are you able to devote to your new dog?

Are you committed to owning a dog for it's entire life which could be 15 years?

Yes

No

What arrangements have been made if you are no longer able to care for the dog (injury or death)?

Please list the name and number of your vet

References: Please provide names, email, and cell numbers for at least two people that are not related to you. Please describe your relationship to them.

Adoption fee varies per dog

I understand that SIMPLY SOUTHERN RESCUE reserves the right to seize any dog/cat that is not being cared for properly.

I understand that SIMPLY SOUTHERN RESCUE is not responsible for any damage or physical harm caused by this dog/cat.

I understand that all future medical expenses past this date, are my full responsibility.

I understand that if my dog/cat gets picked up by animal control it will immediately become property of SIMPLY SOUTHERN RESCUE.

I agree that I have answered the questions to the best of my knowledge and have not knowingly submitted false or misleading replies.

PLEASE SIGN IF YOU AGREE