Name of dog you are interested in (if known):

Your name:* Age:

Address:* City* State* Zip code*

Home Phone: Cell Phone:

NOTE: If you do not provide a phone number, application will be discarded

Best time to call:

Email:*

Employer/Occupation:

Work Phone: May we call you at work: Yes No

Spouse/Partner's Name: Phone:

Personal References who are familiar with you as a pet owner. Not more than one relative please. If your dog(s) require(d) grooming please include your groomer as a reference. If you have adopted a dog from another rescue use them as a reference.

Reference #1.

Name: Phone:

E-mail: Relationship:

Reference #2.

Name: Phone:

E-mail: Relationship:

Do you live in: House Apartment Condo Mobile Home Other

Do you: Own Rent

If renting-Please give us landlord’s Name:

Phone:

If there is a limit on the number of dogs you are allowed, please note the limit:

How long at this address:

If less than 1 year, how long at previous address?

Do you have a securely fenced yard: Yes No

Type & height of fence:

If no fence, how will you exercise the dog & let the dog relieve him/herself?:

How many adults in the household & their ages please list?

How many children, their ages & sex?

Have children been raised with dogs? Yes No

If no children, do you plan on having children someday? Yes No

Do all members of the household wish to adopt this dog? Yes No

Who will take care of the dog?

Are there regular visitors to your home (human & animal) with which your new dog must get along? Yes No

Please list other pets(type, breed, size, age, gender):

Vet's Name:

AddressName:

Phone:

How many dogs have you owned in the past 5 years?

List each dog, giving breed and where the dog is now:

Where will the dog spend the day?

On an average, how many hours each day will the dog spent without human companionship?

Where will the dog sleep at night?

Who will care for your dog when you are on vacations or emergencies?

Have you ever adopted an animal from a rescue or shelter before? Yes No

If Yes-Which recue or shelter was it?

Have you ever released an animal to a rescue or shelter? Yes No

If Yes-Please explain?

What will happen to the dog if you move?

Do you agree and promise to contact the rescue you adopted the dog from if you can no longer keep this dog? Yes No

Are you willing to let a rescue representative visit your home before adoption? Yes No

Have you applied with another rescue organization? Yes No

How did you hear about us (Petfinder, Rescue Me, website, other)?

Signature:* Date:*