EmailMe Form - Adoption Applicaton

Name of dog you're interested in adopting?

Name *

First Last

Date of Birth *

Address *

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

State ID/Drivers License # *

Cell Phone *

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

Email

Occupation *

How many hours a week do you work? *

Do you have access to reliable transportation? *

Yes

No

Have you ever adopted an animal from a shelter or rescue before? *

Yes

No

Do you live in? *

Do you? *

Own

Rent

Lease

Live with parents

If you rent:
Do you have the landlord's written permission to adopt?

Yes

No

Please explain any restrictions (Breeds, Weight, etc)
Also provide landlord's contact information

How long at this address? *

How many adults currently living in the home? *

Do children live at or visit the home? *

Yes

No

Please provide first names and ages of children

Are any of the children special needs?

Yes

No

Does anyone in the house have allergies to animals? *

Yes

No

How would you best describe your household? *

Active

Noisey

Average

Quiet

Do you have a yard? *

Yes

No

If yes, who has access to your yard?

Do you have fencing? *

Yes

No

Do you have a pool? *

Yes

No

Do you have other pets? *

Yes

No

Do you have any livestock? *

Yes

No

Please list all current pets in the home including;
Species, Breed, Age, Sex, if altered or not.

Have you ever had to euthanize a pet? *

Yes

No

Have you ever relinquished a pet to a shelter or rescue? *

Yes

No

Have you ever had an animal confiscated from you? *

Yes

No

Are you financially stable to provide any necessary vet care or emergency vet care if needed? *

Yes

No

Will you provide training should the dog need it? *

Yes

No

Please explain the following:
On average how many hours will the dog be left alone?
Who will primarily be responsible for the dog?
Where will the animal be kept during the day & night? When you're not home?
Any rooms off limits to the animal?

Is the dog allowed on furniture? *

Yes

No

Please explain the following:
What are you looking for in the dog you're interested in adopting?
Would any behaviors cause you to return the dog to the rescue?
Any concerns you'd like to discuss? *

Please explain the following:
What is your experience with other dogs?
Any experience with this specific breed? *

If gone for extended period of time, or in case of emergency or death. What is the long term plan for the dog?
(If relying on friends/family please provide their names and numbers) *

Please provide 3 references not living in the household
(Please include names & numbers) *

Do you have a veterinarian you use? *

Yes

No

If yes, Please provide clinic name and number

Is everyone in the household on board with adopting a new dog? *

Yes

No

When would you like to take the animal home? *