* Required fields
Name *
E-mail Address *
Address
City *
Zip Code *
Occupation *
Phone Number (Home) *
Cell phone number *
Work Number
Name of dog(s) you are interested in. *
Why do you want to adopt a rescue dog? *
If applying for a herding breed (For example...Cattle Dog, Aussie, Border Collie, or a mix of any of these breeds) please tell us about your experience with herding breeds.
How many adults are in your household, including yourself? *
One Two Three Four Five Six Seven Eight Nine Ten
Names of adults in household, ages, and relationship to you? *
How many children (under 18)? Please list their ages... *
If there are no children, do you expect this to change during the lifetime of the pet? *
Yes No
Do you often have people visiting your home? *
Yes No Sometimes
Do you have children visiting on a regular basis? *
Yes No
Who will be responsible for feeding, housebreaking, and training? *
Is every member of the family in agreement to adopt this pet? *
Yes No
Does any member of your family have allergies or asthma? *
Yes No
If yes, what type?
Is someone home during the day? *
Yes No
If yes, who?
How long will your pet be alone on a regular day? *
When I am home this pet will be kept? *
When I am not home this pet will be kept? *
Do you have a doggie door? *
Yes No
If not, will you install one?
Yes No
Where will this pet sleep (be specific)? *
Do you live in a: *
House Townhome Apartment Duplex Condo Mobile Home Boat
Do you own or rent? *
Own Rent
If you rent, what is the name and number of your landlord?
If you had to suddenly relocate or had other drastic lifestyle changes that made it hard to keep your new pet what would you do with him/her? *
Do you plan to take this dog to obedience class? *
Yes No Maybe
Have you ever taken a dog to obedience class? *
Yes No
Do you have a completely fenced yard? *
Yes No
If yes, what type of fencing?
How tall is your fence?
Is there any part of the yard the dog can get out? *
Yes No Not sure
If you do not have a fenced yard how do you plan to keep this pet in your home?
Do you have a pool on your personal property (not a community pool)? *
Yes No
If yes, is the pool permanently gated?
Not applicable Yes No
Will you allow your pet to ride in the open back of a pick-up truck? *
Yes No Maybe
How do you feel about pets living outside? *
How do you feel about chaining or tying a dog? *
Have you ever had a dog/puppy before? *
Yes No
If so, what type of dog?
How long did you have your dog?
If you no longer have this dog...why?
Have you ever had to give up a pet anytime in your life? *
Yes No
If yes, where did the dog go?
Not applicable Animal Shelter Family/Friend Home through newspaper Gave to a rescue Other
If you have given up a dog, why?
Please list all the reasons you can think of that you would not be able to keep your adopted dog. PLEASE BE HONEST WITH YOURSELF…there are always legitimate reasons and this will help us match you with a dog that suits your needs. *
What do you intend to feed your dog (Dog food brand if known)? Wet, dry, or both? *
How do you plan to exercise your dog? *
How often do you plan to exercise your dog? *
Is your dog allowed on the furniture? *
Yes No Only on our laps
Are you willing to adopt a dog that requires housebreaking? *
Yes No Maybe
Do you have a current vet? If so, please provide his/her name, vet office name, phone numer, and city. *
Does your commitment to you new pet include working through issues (ie: fear of strangers, chewing, fear, separation anxiety, walking on leash, etc. *
Yes No Depends on issues
If your answer above stated "depends on issues", please elaborate...
Is there anything else that you'd like for us to know?
Do you have a pet now? *
Yes No
What type of pet(s) do you have (excluding caged pets)?
Is your pet good with other animals?
Not applicable Yes No Not sure Sometimes
If applicable, are your pet(s) spayed or neutered (altered/fixed)?
Not applicable Yes No
If no, please tell us why...
If applicable, where do your current pets sleep?
Not applicable Inside the house Outside Garage
Please list breed, sex, and age of you current pet(s).
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