Address (if this is not complete, we will not respond):
Do you presently own any pets? Yes No If YES, list name and type. (I.e. Sparta-cat)
If you own dogs, are they all spayed/neutered? Yes No If NO, why not?
Please provide us with a veterinary reference (Name and Address)
NOTE: Due to the new federal laws regarding the privacy act, you will need to contact your vet and give permission for us to contact them regarding the status of your pet’s records.
Under what name are your vet records kept? Yes (As given at the top of this form.) Other:
Have you owned pets in the past? Yes No If YES, what kind and what happened to them?
What are your dwellings? House Apt. Other:
Do you have a complete fenced yard? Yes No
If YES, what type? Chain link Wood Other
How high is the fence?
If not fenced, how do you plan on exercising your pet?
Do you own your home? Yes No
If NO, do you have permission from your landlord to keep a dog? Yes No
Name of Landlord
Do you have a crate to keep the dog in? Yes No
How many hours will the dog be alone during the day? ---0123456789101112131415161718192021222324
Where will you keep the dog while you are at work or out on errands?
Where will you keep the dog while you are on vacation?
Why are you interested in adopting a dog?
Do you have a preference for sex, color or age bracket?
(Please note that this is used as a guide only and there is no guarantee that we can find you the dog of your preference- we will still contact you if there is any rescue dog in your area.)
How many adults in your home?
Are there any children presently living in the home? Yes No If YES, what are their ages?
Do you agree to a representative visiting your home to inspect prior to and after adoption? Yes No
Are you willing to enroll your dog in obedience classes? Yes No
Do you understand that a rescue dog will need extra attention and gentle discipline? Yes No
Please provide us with a personal reference: