Revised 07/18/2011

ADOPTION APPLICATION

In an effort to guide us in identifying a compatible rescue dog for your family, please complete this Adoption Application as completely and honestly as possible. Please note that the application is in TWO parts. If you forget to answer a required question, you will receive an error message. Please follow the instructions in the pop-up window: DO NOT use your browser's BACK button, or all data will be cleared and the blank form reset.

 (Required fields are marked with a red asterisk.)

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Contact Information ...
E-mail Address: *
First Name: *
Last Name: *
Address1: *
Address2:
City: *
State: *
Zip Code: *
Phone Number (cell):
Phone Number (home): *
Phone Number (work):
Your household ...
Do your share your residence with a spouse or partner? *yes
no
S/P First Name:
S/P Last Name:
Do you have any roommates? *yes
no
Roommate 1 First Name:
Roommate 1 Last Name:
Roommate 2 First Name:
Roommate 2 Last Name:
Do you have any children? *yes
no
If yes, how many children?
Please list ages:
Your age (please note that you must be at least 18 years of age to apply): *
Age of your spouse or partner:
Age of roommate 1:
Age of roommate 2:
Are there any other household residents? *yes
no
If yes, please explain:
Does anyone in your household have allergies? *yes
no
If yes, to what?
Do you have any grandchildren? *yes
no
If yes, how many grandchildren?
Please list ages:
How often do your grandchildren visit?
Are there other visiting children (under 10 years of age)? *yes
no
Please list ages and frequency of visits:
Your home ... 
Do you rent or own? *rent
own
If you rent, does your landlord or leasing company allow pets? *yes
no
I do not know
NA (I do not rent)
May we contact your landlord or leasing company?yes
no
Name:
Phone Number:
Do you live an a/an ...? *apartment
condominium
mobile home
row home
single detached home
town home
If you live in a house, is it a single-family dwelling?yes
no
If you live in a multi-unit complex or building, approximately how many units are there?
Do you have or have daily access to a yard? *yes
no
Is your yard completely fenced on all four sides? *yes, completely fenced with hard fencing
yes, completely fenced with electronic fencing
no, only partially fenced
no, there is no fence
Please describe, including type of fence and height:
If you have a fence, how is it secured (e.g., locks, latches, etc.)?
Do you share the yard with another family, unit, or house? *yes
no
Do you have a doggy door? *yes
no
Do(es) your current pet(s) have continuous or limited access to the doggy door? *continuous
limited
NA (no doggy door or no current pets)
Please explain:
Do you plan the same for your next dog? *yes
no
Do you have an in-ground swimming pool? *yes
no
If yes, is there a separate fence around it?yes
no
Do you have an aboveground pool, Jacuzzi, or spa? *yes
no
If yes, is there a cover, ladder, or deck around it?yes
no
Do you plan to move within the next year? *yes
no
If yes, when and where?
Employment ... 
Is anyone home during the day? *yes
no
sometimes
Are you currently employed? *yes
no - retired
no - unemployed
Employer:
Position (occupation):
Employer Address1:
Employer Address2:
Employer City:
Employer State:
Employer Zip Code:
Employer Phone Number:
Are you employed ...?full-time
part-time
How many hours per week?
Is your spouse or partner currently employed?yes
no - retired
no - unemployed
S/P Employer:
S/P Position (occupation):
S/P Employer Address1:
S/P Employer Address2:
S/P Employer City:
S/P Employer State:
S/P Employer Zip Code:
S/P Employer Phone Number:
Is your spouse or partner employed ...?full-time
part-time
How many hours does your spouse or partner work each week?
Is roommate 1 currently employed?yes
no - retired
no - unemployed
R1 Employer:
R1 Position (occupation):
R1 Employer Address1:
R1 Employer Address2:
R1 Employer City:
R1 Employer State:
R1 Employer Zip Code:
R1 Employer Phone Number:
Is roommate 1 employed ...?full-time
part-time
How many hours does roommate 1 work per week?
Is roommate 2 currently employed?yes
no - retired
no - unemployed
R2 Employer:
R2 Position (occupation):
R2 Employer Address1:
R2 Employer Address2:
R2 Employer City:
R2 Employer State:
R2 Employer Zip Code:
R2 Employer Phone Number:
Is roommate 2 employed ...?full-time
part-time
How many hours does roommate 2 work per week?
Is it likely that the employment status of any household member will change in the next 1 - 6 months? *yes
no
Is it likely that the employment status of any household member will change in the next 6 - 12 months? *yes
no
If yes, please explain:
* Required