Name

Phone Number

Address

City

Postal Code

Email Address

Dogs name you are interested in (Required)

Have you adopted from us before? Have you adopted from us before? Yes No

If yes, who?

Have you ever surrendered or given up an animal? Have you ever surrendered or given up an animal? Yes No

If yes, how long ago, who took your animal and why did you surrender the animal?

Are you 18 years of age or older? Are you 18 years of age or older? Yes No

Do you have photo ID with proof of age? Do you have photo ID with proof of age? Yes No

Do you expect to move within the next 3 years? Do you expect to move within the next 3 years? Yes No

Are you a home owner? Are you a home owner? Yes No

If no, do you have a permission letter from your landlord? If no, do you have a permission letter from your landlord? Yes No Not applicable

Are all adults in the household in agreement on the adoption of a new pet? Are all adults in the household in agreement on the adoption of a new pet? Yes No

Who will be the primary for the pet's care?

How many adults live in the household?

Number and ages of children in household

Does anyone in the household have allergies to animals? Does anyone in the household have allergies to animals? Yes No

How many hours a day are you and your family away from the home?

Who will take care of your pet if you cannot (vacation, emergency or illness)

What circumstances would lead you to return your pet to us?

I am adopting this animal as: I am adopting this animal as: Companion for myself Companion for my family Companion for other pet Working (herding, hunting, mousing, service, guarding) Other

Have you ever owned a dog before? Have you ever owned a dog before? Yes No

Current number of dogs in household?

Current number of cats in household?

Other pets in the household?

Please provide info on your animals (Breed, age, sex, fixed, length of ownership)

Do your current pets have microchips, licenses, indentification? Do your current pets have microchips, licenses, indentification? Yes No

Are they vaccinated and altered? Are they vaccinated and altered? Yes No

What size of adult dog would you like? What size of adult dog would you like? Small Medium Large

When family is not with the dog, I will keep it: When family is not with the dog, I will keep it: Dog run/loose in yard Chained in yard Barn/garage Loose in house Loose on farm/acreage Crated/room in house

I plan to keep the dog primarily: I plan to keep the dog primarily: Outside Inside Both inside and out With me

I plan to provide exercise by: I plan to provide exercise by: Loose in the house Loose in the yard/property Daily walks on a leash Jogging/biking Off-leash parks

Are there any specific activities you would like your dog to participate in (e.g. jogging, hiking, biking etc.)

How much money do you think you will need to spend yearly on your pet? (including vet, food, supplies etc.

How often do you expect to visit a veterinarian each year?

Do you have a specific vet clinic in mind?

Do you have any experience with housetraining? Do you have any experience with housetraining? Yes No

Do you have any experience with obedience/pet training? Do you have any experience with obedience/pet training? Yes No

Do you understand and agree that adoption is a lifetime commitment? Do you understand and agree that adoption is a lifetime commitment? Yes No

Do you understand how much time, effort and patience is sometimes required for a rescue dog? Do you understand how much time, effort and patience is sometimes required for a rescue dog? Yes No

Do you understand that all the information about the animals are collected within the shelter environment or by third party, therefore we cannot guarantee that the breed, age, behaviour or health listed is correct Do you understand that all the information about the animals are collected within the shelter environment or by third party, therefore we cannot guarantee that the breed, age, behaviour or health listed is correct Yes No

Do you have any additional questions or comments?