First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone

Which dog you are interested in adopting?
Choose an animal: Carrie (DLB) in RI COCO IN RI Corrie (DLB) in RI Journey (OS) aka Jo-Jo in RI Mouse (DLB) in RI Nemo DLR in RI Rambo (JB) in RI Scooter (JC) in AR Siri (DLB) in RI

If there is a particular breed that you are interested in, enter your choice here. Or if the dog's name is not listed above, enter the name in the box.

Preferred Age:*
Choose one: Puppy (0 - 12 months) Young (1 - 4 years) Adult (5 - 9 years) Senior (10+ years) No Preference

Preferred Gender:*
Choose one: Male Female No preference

Preferred Energy Level:*
Choose one: Low Medium High No Preference

Are you willing to adopt a dog with behavioral issues?*

Are you willing to adopt a dog with health problems?*

Your age:*

Are you currently employed?*
Choose one: Full-Time Part-Time Retired Work from home Student Not employed at this time

Name of Employer:

Typical Work Schedule:

What is the best time to call you to review your application?

First Name:

Last Name:

Relation to Primary Applicant:

Cell Phone:

Primary Email:

Age:

Ages of ALL adults (18 and older) other then yourself and co-applicant, currently residing in your household (enter N/A if no other adults):*

Ages of ALL children (under 18) currently residing in your household (enter N/A if no children under 18):*

Have all members of your household agreed to adopt and care for the dog?*

Does anyone in your household have any allergies to any animals?*

If yes, please describe:

In what type of home do you live*
Choose one: Single Family Duplex Condominium Townhouse Apartment Mobile Home Military Housing

Do you own or rent your home*

If you rent, have you received the approval of your landlord to have a pet?*

If you rent, please enter your landlord's name:

If you rent, please enter your landlord's phone number:

Do you have plans to move from your current residence within the next 6 months?*

If Yes, please explain:

Do you have a yard at your residence?*

Is your yard fenced?*
Choose one: Fully fenced Partially fenced Unfenced yard No yard

If yes, what type of fence?
Choose one: Chain Link Stockade/Privacy Invisible

What is the height of the fence?

Do you currently have any pets?*

If yes, please provide the following information for each pet. Please use the format Name/Species/Breed/Gender/Age when entering this information.

Are all current pets up to date on vaccinations and monthly heartworm and flea preventative? Please check all that apply.

If no, is there a medical reason that your pet(s) is not vaccinated? Please explain.

Have all of your other pets, both past and present, been spayed or neutered?*

If no, was there a medical reason your pet was not spayed or neutered? Please explain.

Do all of your current pets either wear ID tags and/or are microchipped?

How many other pets have you had in the past 5 years?*

Please provide details on your previous pets and why they are no longer with you. (passed away, euthanized, given up, etc)

How much time will the animal spend alone during the day?*

If more than 4 hours, do you have a plan to ensure that the dog is cared for?

If yes, please describe:

Where will the dog be when you are away from home? Please check all that apply.

Where will the dog be when you are at home? Check all that apply.

Where will the dog be kept at night? Check all that apply.

Where will the animal be kept when you have company at your home? Check all that apply.

How do you plan to exercise the dog? Please include in your response where you will take the dog to get exercise, and how often the dog will be exercised.*

If necessary, are you willing to take the dog to obedience class?*

Do you have a plan if you travel and are unable to bring the dog?*

If Yes, who will care for the dog, and where?

Do you currently have an established relationship with a veterinarian and/or veterinary practice?*

Name of Veterinary Practice:

City and State

Phone Number:

Please provide the following information for at least two personal references. If you do not have a veterinary reference, please provide a third reference. Do not use a family member as a personal reference.

Personal Reference 1:

Name:*

Phone Number:*

Email Address:

Relationship to You:*

Personal Reference 2:

Name:*

Phone Number:*

Email Address:

Relationship to You:*

Personal Reference 3 (if you do not have a vet reference):

Name:

Phone Number:

Email Address:

Relationship to You:

Additional comments:

Anchor Paws Rescue's adoption contract requires that, should you be unable to keep this dog for any reason, you must return the dog to us. Are you willing to agree to this condition?*
Choose one: Yes No

By submitting this application, I affirm that ALL information is true and complete and that no one in the household where the pet will reside has ever been convicted of animal cruelty or abuse. I agree to give permission for a representative of Anchor Paws Rescue to call the references and veterinary practices I have listed. I also understand that a home visit by an Anchor Paws representative is required for every dog application, and furthermore that Anchor Paws Rescue reserves the right to deny any adoption application with or without disclosure of cause. I also confirm that I have read or been explained the deposit policy for the dog I am applying for. I understand that if any of the information provided in this application or throughout the adoption process is found to have been falsified, my deposit will not be refunded.