First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone

Alt Email

Which animal are you interested in
Choose an animal: Ace Asher BAYLEY Bear Bindi Bridgit Bruno Buck Carma Carter Cooper Freedom Harley Leland Mikey Misty Nicky Ninja Pibbles Scooby Tera Tillie Titch Tug Twinky Wallace

Are you willing to sign a contract?

What is the latest time we can call you?*

List the ages of ALL living in your home (including yourself).*

Who is the dog primarily for?*

Does anyone in your household have allergies?*
Choose one: Yes No

Please list all pets you have at present including: Breed, Name, Age, Sex, Spayed/Neutered (yes or no)

Who in the household will care for the pet*

If your pet is deceased what was the age and cause of death?

Please call your vet and give them permission to speak with us. Veterinarian's Name and Phone Number*

If you have no current vet, please provide the name and number of your past vet. Please call your past vet and give permission for them to speak with us.

List at least two references (who is not a family member) with their telephone numbers.

Where do you purchase heartworm preventive?

How long have you lived at your current address?*

Do you own or rent your home*
Choose one: Rent Own

Will the animal be kept inside or outside*
Choose one: Inside Only Outside Only Inside and Outside

How long daily will the dog be left alone (without humans)?*

Where will the animal be kept when you are not home*

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

Is your yard fenced*
Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

What type of fence
Choose one: Privacy Chain Link Invisible

What is the height of the fence

If you do not have a fenced in yard, how will you insure the dog's safety while outside?

Will you use a tie-out? Explain*

Will the dog always be on a leash?*

Will you use a kennel? Explain

Will the dog be walked daily?*

Will the dog ever be allowed to run free without supervision?*

Describe how you will train the pet*

Have you ever given up a pet? If yes, please explain*

Why are you interested in adopting a pet at this time*

When you move what will you do with your dog?*

Have you applied with any other rescue*
Choose one: Yes No

Do you understand the state and local ordinances concerning licensing and leashing?*

Have you, or any member of your family or household ever been cited for leash law violations or cruelty to animals in the past? if Yes please specify:*

When you go on vacation who will care for your dog and where will it be cared for?*

I/we attest that the information provided on this application is true and accurate to the best of my/our knowledge. I/we understand that completion and submission of this application does not guarantee adoption of a dog. (Submission electronically will serve as signature agreement) Applicant's Name/Signature and Date: *

IMPORTANT: ALL APPLICATIONS WILL BE REVIEWED AS WE RECEIVE THEM, WE DO NOT ADOPT ON A FIRST COME BASIS. ONCE WE HAVE AN APPROVED APPLICATION THAT IS A GOOD FIT FOR THE PUP WE WILL NOTIFY THE APPLICANT. IF YOU ARE TRULY INTERESTED IN ADOPTING PLEASE SUBMIT YOUR APPLICATION AS SOON AS YOU CAN. Any other pertinent information you wish to share: