Applicant Information
First and Last Name: 

Address: 

City: 

State: 

Zip Code: 

Home Phone: 

Cell Phone: 

Email Address: 

Do you own or rent?

If you rent, are there any dog breeds that you are prohibited from having? 

How long have you lived at this address? 

Any plans to move in the near future? 

Landlord’s Name: 

Landlord’s Phone Number: 




Family/Household Information:

Number of adults in the household: 

Relationships: 

Have all the adults in the household agreed to this adoption? 

Number of children in the household: 

Ages of children: 

Have the children had pets before? 

Do you expect your current family situation to change? 

Is anyone in the household allergic to pets? 

If yes, who? 




Employment Information:

Employer: 

Position held: 

City: 

State: 

Zip Code: 

How long have you been with this employer? 

Work Phone: 







Pet Information:

How many pets do you currently have? 

Please list their species, age, sex, and breed (for dogs):




Have you had pets in the past? 

If yes, please list their species and why they are no longer with you:




Have you ever given an animal away or relinquished an animal to a shelter? 

If yes, what were the circumstances? 




Have you ever bred or considered breeding a dog for business or as a recreational pursuit?  

If yes, what were the circumstances? 

Veterinarian Information (if applicable):

Veterinarian’s Name: 

Veterinarian’s Phone: 

When was your current pet’s last visit to a veterinarian and why?

How did you hear about our rescue? (e.g. Craigslist, Petfinder, Referral)?

How long have you been looking for a pet? 

How much time are you prepared to allow for your new pet to adjust to your home? 

Are you committed to providing a responsible home for your pet’s entire life (15+ years)? 

If you have to move, what do you plan to do with your pet(s)? 

Who in the household will be the dog’s primary care giver? 

When you are out of town or during an emergency who will be the dog’s primary care giver?    

Where will the dog be kept during the day? 

Where will the dog be kept during the night? 

How many times per day do you plan to take your dog outside? 

Do you have a fenced yard? 

If yes, what size and what type? 

How many hours per day will your dog be left alone? 

What would you do if your dog develops a problem with the following?




Barking: 

Separation Anxiety: 

Aggression: 




Why do you want to adopt a dog? 







Can you describe the average day for a dog in your household? 







If looking to adopt a puppy, why a puppy?  Are you familiar with the care and training required for a puppy, and what steps will you take to prepare for that responsibility?










References:

Please list 2 personal references below (name, relationship and phone number).




1. 







2.