EmailMe Form - Pre-Adoption General Application

Date *

MM / DD / YYYY

Name of Desired Pet

Name *

First Last

Co-Applicant

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Phone *

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

Cell / Other Phone

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

Email *

Best Time to Contact *

HH : MM AM/PM

Place of Employment

Work Phone

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

Why do you want a rescue dog? *

How far are you willing to travel to pickup your rescue dog? *

Please list names and ages of all HUMANS in your household: *

Please list names and ages of all DOGS in your household: *

Please list names and ages of all CATS in your household: *

Please list names and ages of all OTHER PETS in your household: *

Do all household members want to adopt a dog? *

yes

no

If there are no young children living in your home, will your rescue dog have regular contact with any under the age of 10?

yes

no

If yes, describe:

If there are no other animals currently living in your home, will your rescue dog have regular contact/socialization with others? *

yes

no

If yes, describe:

Do you own or rent your home? *

own

rent

How long at current residence? *

If you rent, has your landlord provided written permission for you to have a dog?

yes

no

Please provide your landlord’s name and phone #:

Do you have a fenced yard? *

yes

no

If yes, please describe (chain, privacy, height, size)::

If you don’t have a fence, are you willing to install one?

yes

no

Do you have dog tie-outs? *

yes

no

Do you have overhead runs? *

yes

no

If yes, length:

Does anyone in your household have allergies or asthma? *

yes

no

If yes, who/what kind?

Are you aware that dogs can shed all year long? *

yes

no

What would you do if someone in your home developed allergies after adopting a dog? *

Who will care for, train and exercise your rescue dog? *

If you do not currently have a dog, have you ever owned a dog in the past for which you were the primary caretaker? *

yes

no

If yes, what happened to the dog?

Have you ever sold, given away, surrendered or put down a pet? *

yes

no

If yes, please explain:

Who is your Veterinarian (provide name & phone #): *

Please list the names of all the animals this vet has treated:

Where will the dog live? *

Where will the dog eat and sleep? *

Will the dog be allowed on the furniture? *

yes

no

Will your dog(s) be allowed free run of the house? *

yes

no

How many hours per day will your dog(s) be home without humans on a regular basis? *

Where will the dog(s) be when you are not home? *

Are you familiar with the use of a dog crate to train and/or confine the dog during your absence or at night? *

yes

no

Are you planning to use a crate? *

yes

no

What will you do with your dog(s) if you need to be away from home overnight? *

Are you aware that the costs of maintaining a dog can average $500 or more a year (food, annual check ups & shots, heartworm & flea/tick prevention, grooming, etc.)? *

yes

no

Will the rescue dog be tied outside? *

yes

no

Will the rescue dog live outside? *

yes

no

Will the rescue dog be walked daily? *

yes

no

Will the rescue dog allowed to run free outside of a fenced yard? *

yes

no

Will the rescue dog receive formal obedience training? *

yes

no

Will the rescue dog have annual vet check-ups? *

yes

no

If you move, what will you do with your dog(s) and other pets? *

May we visit your home prior to the application approval? *

yes

no

Would you allow a follow-up home visit to be done after this adoption? *

yes

no

Are you aware of and do you understand the state/local ordinances concerning dog licensing? *

yes

no

Has any member of your household been cited for licensing or leash law violations?New Field *

yes

no

What would you do if one of your pets requires significant medical attention? *

Date *

MM / DD / YYYY

Would you consider a special needs or handicapped dog that may require medication for a permanent (but controllable) condition? *

yes

no

Anything you would like to add?

By signing below, I/we understand that this is the first step of the adoption process. I/we attest that the information provided on this application is true and accurate to the best of my/our knowledge. I/we have retained a copy of this application for my/our records and understand that completion and submission of this application does not guarantee or entitle me/us to adoption of a rescue dog. *

I Understand

Applicant's Signature *

Clear

Co-Applicant's Signature

Clear