Please take your time and read carefully. Allow at least 45 minutes to complete this appliation.
It is very important that you fill this application out completely. If you do not have your landlord, your references, or your vet's phone number handy, please wait to fill out your application until you do as we will not process applications without them. Also please be sure to fill out the application in its entirety including your driver's license number. Please note that lying on any portion of this application is grounds for having the entire application thrown out with no reconsideration. If you are self employed please describe the business.
Date:
Interested in dog(s):
Why does this dog(s) appeal to you?:
Personal Information
Name:
Birth Date:	JanFebMarAprMayJunJulAugSepOctNovDec12345678910111213141516171819202122232425262728292031 19071986
Home Phone:	- -
Cell Phone:	- -
Street:
City:
State:	Please Select OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip:
Driver's License #:
eMail:
Spouse Information
Spouse Name:
Birth Date:	JanFebMarAprMayJunJulAugSepOctNovDec12345678910111213141516171819202122232425262728292031 19071986
Cell Phone:	- -
Driver's License #:
eMail:
Please list the above information for ANY OTHER ADULTS in the household.
Name, Birth Date, Cell Phone, Driver's License #, eMail:
Housing
Do you live in a:	Select OneHouseApartmentDuplexCondoMobile HomeFarmOther
If Other, please specify
How long have you lived at your current address?:
IF you have lived there for less than five years, please include your previous address
Do you:	Select OneRentOwnLive with FamilyLive with Friends
If You Rent...
Are dogs allowed?:	Select OneYesNo
Are there any breed or size limitations?:	Select OneYesNo
Landlord's Name:
Landlord's Phone:	- -
Do you have yard?:	Select OneYesNo
If you have a yard...
What is your approximate lot size?	Width   feet Depth feet or Approx. acres
Is your yard fenced?:	Select OneYesNo
If you have a fence...
What type:	Select OneWoodAluminumSplit RailElectric FenceInvisible Electric
Height:	feet
Size of fenced area?	Width   feet Depth feet
Fence Comments
Household Information
Number of Children:
Ages of Children:
Number of Adults:
Ages of Adults:
Employer
Average hours per week:
Position:
Employer:
Work Address:
Work Phone:
Length of time with current employer:
Are you self employed:	Select OneYesNo
Spouse's Employer (if applicatable)
Average hours per week:
Position:
Employer:
Work Address:
Work Phone:
Length of time with current employer:
Are you self employed:	Select OneYesNo
Previous Animal Experience
List any animals you currently own. List any dogs first, followed by any cats, then any others.
Pet 1
Name:
Age:
Gender:
Size:
Breed:
Kept inside or outside:
Spayed/Neutered:	Select OneYesNo
Vaccinated:	Select OneYesNo
Receives monthly heartworm:
Receives monthly flea preventative:
Pet 2
Name:
Age:
Gender:
Size:
Breed:
Kept inside or outside:
Spayed/Neutered:	Select OneYesNo
Vaccinated:	Select OneYesNo
Receives monthly heartworm:
Receives monthly flea preventative:
Pet 3
Name:
Age:
Gender:
Size:
Breed:
Kept inside or outside:
Spayed/Neutered:	Select OneYesNo
Vaccinated:	Select OneYesNo
Receives monthly heartworm:
Receives monthly flea preventative:
If you currently own more than three pets, please provide their information here:
How often do you test for Heartworm:
What brand and type of food did/do you feed your animals:
Please list any animals you have owned in the past 5 years:
Were any animals you have ever owned as an adult:
Hit by a car	Select OneYesNo
Put to Sleep	Select OneYesNo
Given Away	Select OneYesNo
Lost	Select OneYesNo
Stolen	Select OneYesNo
If yes to any of the above, please describe the situation:
List any and all veterinarians you have used in the past 5 years.
Vet 1
Name of Doctor/Practice:
Address:
Phone:
Vet 2
Name of Doctor/Practice:
Address:
Phone:
Vet 3
Name of Doctor/Practice:
Address:
Phone:
If you have had more than three vets, please provide their information here:
About Your New Dog
Are all adults aware that you are adopting a pet	Select OneYesNo
Comments
Who will be responsible for the new dog:
How long have you been searching for a dog?:
Why are you looking to adopt a dog:	Select OneCompanionTo BreedFor ChildrenWatch DogHuntingCompanion for other AnimalOther
Comments
Do you intend to keep your dog inside, outside or both?
The dog will be alone (without human companionship) for how many hours, and how many days a week?
Where do you intend to keep your new dog when you are not home?	Select OneCrateOutside (tied)Outside (fenced)BasementGarageOne roomOther:
Comments
Are you open to crate training:
How do you plan to exercise your new dog, do you understand the link between lack of exercise and behavioral problems?
Considering a dog's lifespan can average around 15 years or more...
If you are a senior citizen have you made plans, or thought about what would happen to your dog if you pass away or have to enter an assisted living center. Please describe any options you have considered:
Dogs have been returned to us for a variety of reasons including Death (unexpected)Development of allergies (mostly in children), Sudden Illness, Too Energetic, Moving, Change of Job, Unexpected birth of a child. Please list at least one case where you would give up a pet. If you can't think of any please indicate what would happen to your dog in the unforeseeable instance that you have to give up your pet.
Do you plan to attend obedience classes? How do you intend to reprimand your new dog?
If a veterinarian diagnosed a condition that would cost over $200.00 to treat what would you do?
What will you do if your new dog...
Urinates in the house?
Chews inappropriate items?
It may take a month or longer for your new dog to adjust to its new home. Two example issues are: A dog considered housebroken starts having a few accidents. The dog begins to develop separation anxiety. Are you prepared to handle this?
What kind of identification do you intend to keep on your dog?
What do you plan to do with your dog while you are away or on vacation?
Have you ever adopted an animal from Animal-Rescue?"	Select OneYesNo
IF YES, Who and When?
Have you ever adopted an animal from any other shelter before?"	Select OneYesNo
IF YES, please give the Name, Location and Phone Number of that shelter?
How did you hear about Animal-Rescue?
Have you ever:
Surrendered a dog to another shelter:	Select OneYesNo
Adopted but returned a dog to a shelter:	Select OneYesNo
Applied for a dog, but were denied at any other shelter?:	Select OneYesNo
If you answered yes to any of the above questions please include the shelter's name, location, and phone number and a description of the situation.
References
Reference 1
Name:
Relationship:
Phone:
eMail:
Reference 2
Name:
Relationship:
Phone:
eMail:
By my submitting this form, I certify that the above statements about me and my history with companion animals are true and correct. I understand that Animal-Rescue reserves the right to refuse any applicant for any reason. Any misrepresentation of fact may result in my application being rejected. I understand that by signing this document I verify that I am at least 21 years old. My signature to this document also permits my present (or previous) Veterinarian or Animal Hospital to release requested information to an Animal-Rescue volunteer regarding my current or previously owned pets for the purpose of considering my application for a companion pet. I will not hold Animal-Rescue or any of its volunteers responsible for any actions incurred once the animal has been released from their care. If I have not been contacted within 14 days from the date of this application from an Animal-Rescue representative, I understand that my application has been declined or the dog which I have requested has been placed with another family.
I understand and accept your above terms.