EmailMe Form - Adoption Application

Name (First and Last) *

Address *

City, State and Zip Code *

Email *

Single or Married? *

Single

Married

Phone Number *

### - ### - ####

Alternate Phone Number

### - ### - ####

Age

Occupation

If you've seen a pet on our availability list, please tell us which one. If you are simply seeking a pet, please tell us what characteristics you are looking for in a pet. Ie. puppy, adult, senior, house trained etc. *

Can you tell us where the dog will stay during the day or evening. For example, if you work, it will stay in a crate for 8 hours, or it will be placed outside in the yard for 8 hours?

Please include if the pet has any companion ship during those hours. For example, is there another person home if you are at work or do you have another pet that is friendly to your new family member? *

Answering the above questions, can you indicate how long the pet will spend its time inside, outside, in a crate etc.

If spending time outdoors, please indicate if your property is properly fenced in to prevent escape. *

Where will the pet spend most of its time? *

Inside

Outside

Both Inside and Outside

Crate

General Housing Question. Do you live in a *

House

Apartment

For specific Day/Hour availability, please enter information below.

Are you planning on moving anytime soon? *

Yes

No

Not sure

If you are planning on moving, will you be able to take the pet with you and have already made the necessary arrangements for travel and with the new living quarters facility if you are leasing or renting?

Please indicate how you will transport the pet also. *

Does your landlord require a deposit for having pets? If so, please indicate any such associated fees. *

Please provide us contact information of the facility you are leasing or renting your living quarters from. We will only ask if pets are allowed and do a typical reference check.

If needing to leave the dog alone for periods of time, whether inside, outside, in a garage etc.

Please indicate where you would normally place the pet and your methods of confinement. Ie. chained, leashed etc.

What type of food do you intend on feeding your new pet?

Wet/moist, dry, a combination of wet/dry, homemade etc. *

If you have or are seeking a vet please provide their contact information. *

If you have any other pets, please list them, their age, genders, breeds and any other information such as special needs/illnesses. *

Can briefly explain why you are seeking pet ownership? *

Please list at least 2 references. Include their names and contact information, their relationship to you and years known. *

If there is anyone else living with you, are they aware you are seeking pet ownership and are they also for it? *

Yes

No

Can you approximately estimate what you would think it would cost you to have a dog? *

Please list all persons living with you. Please include ages. *

If your pet should become very ill requiring a lot of medical attention. What would be your response or method of handling a financial burden? *

What would you consider valid reasons for giving up your pet? Too expensive, too much barking, illness,
dirty, having a baby and so forth.

Please list all the reasons you would think is a valid reason for giving up your pet. *

If you could no longer take care of your pet, what would you do? Do you have a backup plan if you shall become ill or lose your employment etc.?

Please explain. *

Are you familiar with local laws regarding pet ownership? *

Yes

No

Would you permit YROA performing a walk through of your home to ensure it is a safe environment? For example, fenced in property, no bare wires hanging from the wall outlets etc. *

Yes

No

Are you committed to caring for your pet new family member whether its medical checkups, dental visits and so on? *

Yes

No

We would like to keep in touch with the new Yorkie owners to insure your Yorkie is doing well for the first year. Would you be willing to send emails with photos or allow a home visit? *

Yes

No

Read the following carefully.

I declare that the information I have provided in this application is complete and correct. I further declare that I am physically able to care for a Yorkshire Terrier. I understand the requirements and grant permission for home checks at random, both prior to and following adoption. I submit that if a home check reveals falsification or misrepresentation of any facts on my part, Yorkie Rescue of America reserves the right to either refuse adoption or to nullify the adoption and reclaim said Yorkshire Terrier from my premises without reimbursement of the adoption donation. I release Yorkie Rescue of America from any liabilities I may incur from the adoption process.

Do you agree with the terms and conditions? *

Yes, I agree.

Initial *

Date *

MM / DD / YYYY