* Required Fields    

           * Which dog are you interested in adopting?       * Today's Date-- mm/dd/yy              

First Name	Last Name
Street Address	Alt. Address
City	StateZip Code
Day Phone	Evening PhoneLicense NumberState
E-mail	Alt E-mail

Please answer the following questions:

           Applicant's background:

 

Do you own or rent your home? Pick One Rent Own How long have you lived there? May we contact your landlord? Pick One Yes No

If you  rent, please provide your Landlord's name and phone number

Are you planning to move within the next year? Pick One Yes No Please explain

---

About the House:

Adults in your household? Pick One 1 2 3 4 5 More How many children? Pick One 1 2 3 4 5 More Ages? Pick One 0-1yr 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Known allergies?

Do all adults in your home know you are considering adopting a pet(s)? Pick One Yes No Is your yard fenced? Pick One Yes No

Where will your pet(s) spend the day? Where will your pet(s) spend the night?

 How will it be exercised?How will it be confined to your property?

Is outside shade available? Pick One Yes No What is the outside shelter?

---

Dog/Owner History:

Do you have any other pet(s) now? Pick One Yes No Name:Type, Age, and Sex:

Who will care for your pet(s) if you are away?

What are your reasons for adopting this dog?

Have you ever taken a pet(s) to a shelter? Pick One Yes No Yes, Reason?

If left alone, how will your pet(s) be confined/amused to prevent destructive behavior?

---

Vet Information:

Veterinarian? Where is this vet located?

 Phone number? Are your pet(s) currently a patient there? Pick One Yes No

Are you familiar with licensing and leash laws for your town? Pick One Yes No

---

References:

Please list at least two(2) non-family references, their relationship to you, and their phone numbers. We may be contacting them regarding this application.

Reference1:

Name RelationshipPhone Number

Name RelationshipPhone Number

---

"I Believe that we can make a difference, one dog at a time." 

I Believe Dog Rescue reserves the right to refuse any adoption which it feels is not in the best interest of the animal and you. The animals here will require patience, understanding, time and training in order to become the friend you want them to be. The period of adjustment will be different for every animal. I Believe Dog Rescue can not guarantee the health or temperament of any dog.

I, the undersigned, have read and truthfully answered the questions on this application. I understand that I Believe Dog Rescue has full authority to approve or deny my application. I realize that any false information could result in forfeiture of the animal. By signing this you agree to the terms in this application. Please place your name and date below, this is an electronic signature and will be used to bind this application.

Signed: Date: