Rescued small dogs

1. Name of dog interested in:
2. Your Name:
3. Address:
4. City:
5. State:
6. Zip:
7. Home Phone:
8. Cell Phone:
9. Work Phone:
10. Email Address:
11. Best Time to Call:
12. How did you hear about us?
13. Age range and gender of adults in household:
14. Occupations:
15. Age and gender of children in the household (anyone under 18 years old):
16. Do you plan on having children in the next 5 years?
17. Are any members of your household allergic to animals?
18. Are there other visitors to your home, human or animal, with which a new dog will have to interact?
19. Do you live in a House, Apartment, Trailer, Other (Describe)?
20. Describe your property (busy street, acreage, etc.):
21. Do you own or rent your home?
22. If you rent, do you have landlord's permission to keep a dog?
23. Name of Landlord:
24. Phone No:
25. How long have you lived at this address?
26. Do you plan on moving in the next few years?
27. Do you have a completely fenced yard suitable for a dog?
28. Do you have a kennel run or tie out for a dog?
29. Describe fence, kennel run type or tie out (height, size, intended use):
30. If no fence, how will you handle exercise and toilet needs?
31. Do you have a suitable dog crate?
32. How many hours a day must the dog be alone?
33. Where will the dog be if left alone?
34. Are you planning to enroll the dog in obedience/training class?
35. Who will be the primary care give for the dog?
36. Describe a typical day in the dog's life with you and in your home:
37. What activities do you plan with this dog?
38. Do you intend to keep this dog primarily inside or outside?
39. Where will the dog sleep?
40. Why have you decided to adopt a dog?
41. Why did you choose this dog?
42. Have you had a rescue dog before? If yes, describe your experience:
43. Please list the dogs and other animals currently in your home (age, sex, breed, temperament, socialization with dogs). This question must be answered in full.
44. Are the animals currently in your home neutered or spayed?
45. How many dogs have you owned in the past five years that are currently not in your home?
46. Why do you no longer have them?
47. Have you ever adopted a dog from another rescue agency and were unable to keep it? Please tell us what happened in detail.
48. Please tell us what the 5 most important traits in a dog that are important to you:
49. Do you realize that a dog can cost in the upwards of $600 a year between regular vet visits and food. This amount does not include emergency trips to the vet office for those un expected situations. Are you able and willing to take on that financial responsibility?
50. Do you realize that owning a dog is a 15 - 20 year commitment?
51. Do you have a regular veterinarian?
52. Name:
53. Phone Number:
54. Would you be willing to consider a suitable dog of a different sex, age or breed (be specific)?
55. Personal Reference
56. Relationship:
57. Phone:
58. I agree that all of the information I have given in this adoption form is true and complete. I agree that this dog will reside in my home. I will provide the dog with adequate food, water, shelter, training, affection and medical care and the dog will not be tied out or on a run. I understand that the rescue is not responsible for the accuracy of information received about the temperament, habits or physical condition of the dogs available for adoption. However, all information provided is given in an effort to do the best in knowing a dog prior to adoption. Please initial ______________ (or type the word "YES")

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