NO PETS LEFT BEHIND											
											
Adoption Application - Dog											
											
	"PLEASE NOTE: Completing this application is merely the first step towards adopting a dog. 
	By submitting this completed application, you are neither guaranteed nor obligated to adopt. 
	This is merely the beginning of a process that will include vet references, phone interviews and home visits."										
											
	Date:			


1	First Name:										

2	Last Name:										

3	E-mail Address:										


4	Street Address:										

5	City/Town:										

6	State:										

7	Zip Code:										
											

8	Home Phone:										

9	Work Phone:										

10	Cell Phone:										


11	Best Time To Call:										


12	Occupation(s):										


13	How long have you lived at your present address: 			(years / months)			


14	Do you rent or own your home:          OWN   	or   RENT					
	
	* Please note that renters must include documentation from the rentor that dogs are allowed to 
	live in this dwelling.										


14a	Do you have a fenced-in yard?          YES	or       NO			Fence Height?		



15	If you move what will you do with this pet: 										



	Where will the pet be kept:										

16	During the day: 										

17	During the night: 										

18	When no one is home: 										

19	When on vacation: 										



20	On average how long will this pet be left alone each day:										


21	Does anyone in the household have allergies to dogs? 		YES		NO		


22	Who will be responsible for this pet: 										



	"Please provide name and contact information for your veterinarian, or the one you will use
	 with this pet:
										
23	Vet Clinic Name:										
24	Address:										
25	Phone Number:										


											
	*Please list two other references we may contact regarding this adoption:
										
26	Reference #1: 									
	Name:									
	Address:									
	Phone Number: 									
	E-mail Address:									
										
27	Reference #2: 									
	Name:									
	Address:									
	Phone Number: 									
	E-mail Address:									

										
28	Please list all the types of pets you have owned in the last five years:									
										


										
											
	   										
29	"Please list all types of pets(cat, dog, etc) including breed, age and gender that currently 
	live in the household:"										
											
		Type		Breed			Age	Spay or Neuter?		Gender
											
											
											
											
											
30	"If you have lost a pet or it died at an early age or due to an accident, please provide details: "										


											
											
31	"If you have ever given up a pet or put one to sleep, please provide details: "										


											

32	If you have ever surrendered a pet to a shelter or rescue group before please provide details: 										


											

33	"How much money do you plan on spending on this pet each year (food, vet, boarding, toys, etc.)? "										


											
	  										
34	Describe your reason for wanting to adopt a dog:										


											
											
35	Would you be willing to accept a dog with some health problems:   	YES		NO	

36	Would you be willing to accept a dog that is not housetrained:   	YES		NO	

37	Would you be willing to accept a dog with some behavior problems:  	YES		NO	
											
38	Would you consider adopting a senior dog:				YES		NO	


39	"Explain the size, sex, color and personality of the dog you prefer to adopt."										

											

											
40	What age range would you consider adopting?

										

41	LIST ALL ADOPTERS RESIDING IN THE HOUSEHOLD (include yourself and children in the household):
  										
		Name					Age		Relation		
											
											
											
											


											
											
											
42	If no children are listed above are there plans for children in the future?      YES	NO	
											


43	How many children VISIT your home and what are their ages:										
											
											
											
44	Have you filled out an application with other rescue organizations?		YES	NO	

											
45	COMMENTS:										
											
											
	"By submitting this form you are certifying that all information contained above is true and 
	correct. That you are over 18 years of age and the person responsible for making pet decisions 
	in your family. That you are looking to adopt a pet, give it a good and loving home as a 
	pet owner and accept full responsibility for his/her care."										
	
	I agree to abide by all state and local pet control laws. I understand it is my responsibility 
	to become familiar with these laws. 										
	
	
	Signature:  ____________________________________________    Date:  ____________________										
	
	
	The next step is to provide your Rescue Agent with this completed adoption application by 
	emailing it or mailing it back to the address below.  Your application will be reviewed 
	and if additional information is needed you will be contacted and a home visit will then 
	be scheduled.										


											
	Carla Rasmussen	 crasmussen@cox.net	7125 So. 137th Ave.  Omaha, NE  68138	402-895-5850	

	Cari Smith	 carimcsmith@yahoo.com	4136 R Street        Omaha, NE  68107	402-614-5718