First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Cell Phone

WHICH ANIMAL ARE YOU INTERESTED IN?
Choose an animal: Banjo Gizmo Sandy #2 Toby

If interested in more than one animal please list Second Choice?
Choose an animal: Banjo Gizmo Sandy #2 Toby

APPLICANT EMPLOYER:

APPLICANT OCCUPATION:

SPOUSE/ROOMMATE NAME?

SPOUSE EMPLOYER:

SPOUSE OCCUPATION:

LIST AT LEAST TWO REFERENCES THAT ARE NOT A FAMILY MEMBER:

REFERENCE PHONE NUMBER:

REFERENCE #2 NAME:

REFERENCE PHONE NUMBER:*

IN WHAT TYPE OF HOME DO YOU LIVE IN?
Choose one: Single Family Duplex Apartment Condominium Mobile Home Military Housing Motorhome or RV

HOW LONG HAVE YOU LIVED THERE? (IF LESS THAN TWO YEARS PLEASE PROVIDE PREVIOUS ADDRESS)

DO YOU RENT?*

IF YOU RENT, DO YOU HAVE PERMISSION FROM YOUR LANDLORD TO HAVE AN ANIMAL?
Choose one: Yes No

IF YOU RENT, MAY WE CONTACT YOUR LANDLORD?

LANDLORDS NAME:

LANDLORD PHONE NUMBER:

ARE YOU PREPARED TO TAKE ADEQUATE CARE OF THIS ANIMAL IF IT BECOMES ILL OR INJURED?

NAME OF VETERINARIAN/HOSPITAL:

VETERINARIAN PHONE NUMBER:

DOGS CAN LIVE FOR MORE THAN 15 YEARS, AND THEIR CARE MAY AMOUNT TO OVER $400.00 PER YEAR. ARE YOU PREPARED TO ACCEPT THIS RESPONSIBILITY FOR HIS/HER ENTIRE LIFE?

WOULD YOU OBJECT TO AN INSPECTION OF YOUR PREMISES BY A RESCUE VOLUNTEER?

DO YOU PLAN TO LICENSE THIS ANIMAL?

ARE YOU WILLING TO ATTEND OBEDIENCE CLASSES?

HAVE YOU INQUIRED ABOUT CLASSES?

IF YOU WERE TO HAVE POTTY TRAINING ISSUES WITH THIS DOG, HOW WOULD YOU ADDRESS IT?

HOW MUCH TIME WILL THE ANIMAL SPEND ALONE DURING THE DAY:*

WHERE WILL THE ANIMAL SLEEP AT NIGHT: AS A PUPPY? AND AS AN ADULT?*

WILL THE ANIMAL BE KEPT INSIDE OR OUTSIDE:

WHAT TYPE OF OUTDOOR SHELTER IS AVAILABLE FOR THE DOG:

IS ANYONE IN THE HOME ALLERGIC TO ANIMALS?

HOW MANY ANIMALS DO YOU OWN? DOGS, CATS, OTHER, WHAT BREED & AGE ARE THEY?

ARE YOUR OTHER ANIMALS LICENSED?

DO YOU HAVE A SWIMMING POOL?

IS YOUR YARD FENCED?*
Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

WHAT TYPE OF FENCE:
Choose one: Brick Chain Link Invisible Privacy Vinyl Wood

WHAT IS THE HEIGHT OF THE FENCE?

HOW MANY PEOPLE RESIDE IN YOUR HOUSEHOLD: ADULTS, CHILDREN,

AGES OF ALL CHILDREN IN HOME:

WHO IN THE HOUSEHOLD WILL CARE FOR THIS PET:

HOW DO YOU PLAN TO PROVIDE FOR THE DOG WHEN YOU ARE OUT OF TOWN?

WILL THE ANIMAL HAVE FREE ACCESS TO ROAM THROUGHOUT THE HOUSE*

WHAT WILL HAPPEN IF YOU MOVE LOCALLY - OUT OF TOWN OR OVERSEA?

UNDER WHAT CIRCUMSTANCES WOULD YOU NOT KEEP THIS ANIMAL?*

HAVE YOU EVER GIVEN UP A PET? IF YES, PLEASE EXPLAIN:*

WHY ARE YOU INTERESTED IN ADOPTING A PET AT THIS TIME?

I CERTIFY THAT THE ABOVE INFORMATION IS TRUE, AND THAT ANY FALSE INFORMATION MAY RESULT IN NULLIFYING THE ADOPTION. I ALSO UNDERSTAND THAT COMPLETING THIS APPLICATION DOES NOT ENSURE THAT I WILL BE SELECTED TO ADOPT THIS DOG.

Signature: Date: