First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Home Phone*

Which animal are you interested in*
Choose an animal: Adzuki Anasazi Ayla Bacon Butterbean Cannellini Deena Grace Kobe Lil' Bean Lupini Pintos Rusty Scout Skip Vegas

Explain your interest in this dog

Explain your interest in this breed

Do you have a vet?*

Veterinarian's Name

Vet Address

Vet City

Vet Phone

Length of Relationship

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

Is your yard fenced*
Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

What type of fence
Choose one: Privacy Chain Link Invisible

What is the height of the fence

Do you own or rent your home*
Choose one: Rent Own Other

If you rent, please enter your landlord's name and phone number*

If you rent, have you received the approval of your landlord to have an animal
Choose one: Yes No

Who is your home owners or renters insurance provider*

How many people reside in your household*

How many children are in the house*

If children are present, what are their ages?

If other adults are present, please provide their names and relation to you

Please list all animals currently living in your home

Are all of your animals spayed/neutered

Are all your animals up to date on vaccinations

Please list your past animals and why they are not with you any more.*

Will the animal be kept inside or outside*
Choose one: Inside Only Outside Only Inside and Outside

Where will the animal sleep*

Where will the animal be kept when you are not home*

Where will the animal be kept when you are home*

Who in the household will care for the pet*

Describe how you will train the pet*

What issues are you willing to work with*

What issues are you not willing to work with*

Reference #1*

Reference #1 Phone*

Reference #1 Email

Reference #1 Relation to you:*

Reference #2*

Reference #2 Phone*

Reference #2 Email

Reference #2 Relation to you*

Reference #3*

Reference #3 Phone*

Reference #3 Email

Reference #3 Relation to you*

Why are you interested in adopting a pet at this time*

How did you hear about us*

What are your thoughts on Spay/Neuter*

Are you applying with other rescues?

Do you have any comments or questions

I have read the Adoption Process, Policies and FAQ on the website

I am at least 18 years of age

I certify that the information entered on this applicant is true. Enter your name and date*