Adoption Application

Adoption Application

Please complete all sections of this form.
Astericked fields are required.
Please note that our adoption fee is $250.00

First Name: *
Last Name: *
Street Address: *
City: *
State: *
Zip Code: *
Home Phone: *
Work Phone:
Cell Phone:
Email Address: *
Confirm Email Address: *
Name of Dog You Are Interested in Adopting:
Is this dog a gift for someone? If yes, please explain:
Why do you want to adopt a dog at this time?
Who will be primarily responsible for the care of this pet?
How long have you lived at your current address? :
What type of dwelling do you live in?
Do you rent or own this dwelling?
If renting, landlord's name and phone number. *Please note that we must contact your landlord in order to verify that you are allowed pets*
Please list below all pets you have owned in the last 5 years:
First Pet: Pet's Name:
Breed:
Years Owned:
Age:
Living with you?	Yes No
Is the pet spayed/neutered?	Yes No
Is the pet current on vaccines?	Yes No
Is the pet current on heartworm preventative?	Yes No
Second Pet: Pet's Name:
Breed:
Years Owned:
Age:
Living with you?	Yes No
Is the pet spayed/neutered?	Yes No
Is the pet current on vaccines?	Yes No
Is the pet current on heartworm preventative?	Yes No
Third Pet: Pet's Name:
Breed:
Years Owned:
Age:
Living with you?	Yes No
Is the pet spayed/neutered?	Yes No
Is the pet current on vaccines?	Yes No
Is the pet current on heartworm preventative?	Yes No
Fourth Pet: Pet's Name:
Breed:
Years Owned:
Age:
Living with you?	Yes No
Is the pet spayed/neutered?	Yes No
Is the pet current on vaccines?	Yes No
Is the pet current on heartworm preventative?	Yes No

Name and phone number of veterinarian: *Please note that we must contact your veterinarian in order to verify that you are a client.*

List the name and ages of all members of your household:
What is your reason for adopting this animal?
Do you have a fenced yard?	Yes No
If yes, how high is the fence?
Is your yard fully fenced (all 4 sides) or partially fenced?
Please explain how and when you will exercise the pet and allow it to relieve itself:
Where will your dog spend most of its time when you are at work or out?
If "Other", please explain:
How long will the pet be left alone each day?
Where will your pet stay while you vacation? Are you planning a vacation within the next few weeks?
What would you do with your pet if you move and your pet was not allowed?
Do you have contingency plans in place for your pet if something were to happen to you? if so, please explain:
In what situation would you allow your dog to run off-leash or in an open/unfenced area?
Explain under what circumstances would you return this dog to us? (i.e. Sheds too much, moving, getting a divorce, having a baby, dog too active)

Please provide two personal references (not relatives) who can recommend you as a responsible pet owner:
Reference 1 Name:
Reference 1 Phone:
Reference 1 Relationship:
Reference 1 Years Known:
Reference 2 Name:
Reference 2 Phone;
Reference 2 Relationship:
Reference 2 Years Known:
Will you crate train this dog?	Yes No
Have all family members discussed adopting a new pet?	Yes No
Do any family members have any animal allergies that you are aware of? If yes, please explain
Are you willing to seek professional advice if your pet displays destructive or negative behavior?	Yes No
Do you have a swimming pool?	Yes No
Are you willing to provide extensive and expensive medical care to your pet if an emergency or illness arises?	Yes No
Will you allow us to make a home visit to verify your application?	Yes No
Will you agree to 3-month, 6-month and yearly follow ups?	Yes No

May we add you to our mailing list?	Yes No

By submitting this application, I hereby give permission to Coming Home Rescue, Inc. to contact my veterinarian to obtain information about past and present pets. I also allow and authorize Coming Home Rescue, Inc. to verify the above information. I certify that all questions have been answered honestly and accurately and I authorize you to contact anyone listed on this application. I understand that Coming Home Rescue, Inc. reserves the right to refuse any adoption application without further explanation.

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