NAME______________________________________________________________________
 
ADDRESS____________________________________________________________________

CITY__________________________________STATE__________________ZIP___________

PHONE (HOME)______________________(WORK)_______________

OWN HOUSE___ RENT HOUSE___ LIVE IN APT___

HOW LONG AT CURRENT RESIDENCE_______

LANDLORD PHONE________________
(if applicable)

PLAN TO MOVE? ___________WHEN________________WHERE__________________________

OCCUPATION _________________________________________________________

VETERINARIAN_________________________________ PHONE ______________________

NON-FAMILY MEMBER REFERENCES:

1) NAME: ___________________________________ PHONE: ___________________

2) NAME: ___________________________________ PHONE: ___________________

HOW MANY IN HOUSEHOLD?

 ______ CHILDREN   _______ ADULTS

 ______ AGES OF CHILDREN
(if applicable)
 
HAVE CHILDREN BEEN RAISED AROUND DOGS?   YES ____  NO ____
 
WILL RESCUE ANIMAL HAVE CONTACT WITH CHILDREN? YES___NO___
 
                                          HOW OFTEN____________

DO YOU HAVE OTHER PETS NOW? YES___ NO ___

(if yes) DOGS CATS BIRDS OTHER ________________

OTHER PETS’ NAMES, SEX, AGES_____________________________________________

ARE OTHER PETS SPAYED/NEUTERED__________________________________________

ARE THEY CURRENT ON VACCINATIONS_____ LICENSED_______

HOW DO YOUR CURRENT ANIMALS ACT WITH OTHER PETS?________________________________________________________________________________________________________________________________________________________
 
LIST DOGS PREVIOUSLY OWNED_____________________________________________

HOW LONG_____________WHAT HAPPENED TO THEM________________________________

WHY DO YOU WANT AN RESCUE ANIMAL?_____________________________

WHERE DID YOU LEARN ABOUT MY ORGANIZATION?______________________

WHAT DO YOU KNOW ABOUT DOGS, CATS,(ANIMAL UP FOR ADOPTION)_______________
____________________________________________________________________

HOW WOULD YOU PREVENT AGGRESSION TOWARD OTHER PETS BE ANY ANIMAL OF YOURS THAT WAS ADOPTED?
_______________________________________________________________________
_______________________________________________________________________
 

HOW MUCH TIME WILL YOU SPEND WITH YOUR RESCUE DAILY?___________________

WHERE WILL THE ANIMAL STAY WHEN YOU ARE AT WORK?______________________

WHERE WILL THE ANIMAL SLEEP AT NIGHT?___________________________________

HOURS ANIMAL WILL BE ALONE DAILY?2-4HRS____4-6HRS____7-9HRS_______9HRS+_____

DO YOU HAVE A FENCED YARD? YES___ NO___

(if yes to fence) HOW HIGH?_____ TYPE_________

WHEN WILL ANIMAL BE OUTSIDE?_________________________

WILL ANIMAL BE TIED OUT AT ANY TIME?YES_____NO_______MAYBE_____EXPLAIN

If yes, HOW OFTEN?________

WILL ANIMAL BE TAKEN FOR WALKS?YES____NO_____MAYBE______
If yes, HOW OFTEN? _______

WHO WILL WALK ANIMAL?________________________

WILL YOU BE WILLING TO OBEDIENCE TRAIN ANIMAL YES_________NO______MAYBE______

WILL YOU CARE FOR THE ANIMAL FOR ITS LIFE? YES__ NO___ MAYBE___

MAY A REPRESENTATIVE VISIT YOUR HOME BY APPOINTMENT? YES___ NO___ MAYBE___

ARE YOU WILLING TO PAY THE ADOPTION FEE FOR THIS ANIMAL?  IF UNABLE, PLEASE EXPLAIN FOR CONSIDERATION