Please enable JavaScript in your browser to complete this form.Animal NameGenderMaleFemaleYour Name *FirstLastYour AddressDriver's License NumberDate of BirthPhone NumberEmail *Address where pet will liveWho will be responsible for pet? Have you ever owned a dog before?YesNoIf yes please tell us what happened to your previous dogs.Do you currently have any pets?YesNoIf yes please list all current pets and ages. Are they spayed/neutered? YesNoAre your pets vaccinations current? YesNoWhat type of heartworm prevention do you use?Are you familiar with heartworms and heartworm prevention? Current Vet – Name/Address *Current Vet Phone NumberMay we contact your veterinarian for a reference? YesNoPlease call and give authorization for them to speak with us.Please call and give authorization for them to speak with us.Do you have a fenced yard? YesNoType of fencing Will your pet be kept indoors or outdoors? How long will your pet be left alone on a daily basis? Do you have children in your home? If yes, please provide the ages of children.Does anyone in household have animal allergies? Does everyone in the household agree on adopting this pet?If you rent your home we will need to contact the property owner/manager please provide contact information. Please provide Property owner/manager name and phone number.Do you agree to a home visit by a rescue volunteer? YesNoUnder what circumstances would you find it necessary to find a new home for your pet? *Most shelter/rescue dogs have unknown medical histories. Are you willing to take your new dog to a veterinarian for an initital exam and any necessary treatment at your own expense? YesNoWhy do you want to adopt this pet? *Please check each line below indicating your understanding, agreement and acceptance: Any adoption fee is NON-REFUNDABLE.You will return the animal to us if you feel you cannot keep him/her. You cannot sell or give the pet to anyone else, or surrender pet to a shelter.You have the ability to care for your pet and your pets needs financially.Your pet MUST be vaccinated.If requested you will furnish Rescue with proof of current vaccinations for a 24 month period following adoption.Checking the box below certifies that the above information is true and correct to the best of your knowledge. Any false information will lead to the denial of your application. The Rescue reserves the right to annul the adoption and reclaim the animal for any falsification of information or failure to follow all agreements contained in this application after the adoption. The adoption decision is based on many factors. The Rescue reserves the right to refuse any adoption at our discretion. Your signature certifies that the above information is true and correct to the best of your knowledge. Any false information will lead to the denial of your application.I Agree YesNoName Submit