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:				
    	
First Name:										
Last Name:										
E-mail Address:
			
Street Address:										
City/Town:										
State:										
Zip Code:		
    												
Home Phone:										
Work Phone:										
Cell Phone:										
Best Time To Call:
    	
Occupation(s):										
Do you rent or own your home:                       					
* Please note that renters must include documentation from the rentor that dogs are allowed to 
live in this dwelling.
    	
How long have you lived at your present address: (years / months)											
Do you have a fenced-in yard?                                           If so, Fence Height?		
If you move what will you do with this pet: 										
    	
Where will the pet be kept:										
During the day: 										
During the night: 										
When no one is home: 										
When on vacation: 										    	

On average how long will this pet be left alone each day:										
   	
Does anyone in the household have allergies to dogs? 		
    	
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:
    	
Vet Clinic Name:										
Address:										
Phone Number:								
    	
Please list two other references we may contact regarding this adoption:
    	
Reference #1: 									
Name:									
Address:									
Phone Number: 									
E-mail Address:								
    	
Reference #2: 									
Name:									
Address:									
Phone Number: 									
E-mail Address:	
   	
Please list all the types of pets you have owned in the last five years:									
Type		Breed			Age	Spay or Neuter?		Gender
    	

    					 
    	

    						   										
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
    	

    						 
    	

    						 
    	

Do you use Heartworm preventative for you current pet/pets? 								
    	
Do you use flea and tick preventative for your current pet/pets? 	
    	
If you have lost a pet or it died at an early age or due to an accident, please provide details:	
    	

    						 
    	

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

    						 
    	

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

    						 
    	

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

    															
    	  										
Describe your reason for wanting to adopt a dog:										
    	

    						 
    	

    						 
    	

Would you be willing to accept a dog with some health problems:   
    	

Would you be willing to accept a dog that is not housetrained:   	      
    	

Would you be willing to accept a dog with some behavior problems:  	
    	

Would you consider adopting a senior dog:				                	
    	

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

    					 
    	

    														
What age range would you consider adopting?	
    	

    						 
    	

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

    					 
    	

    					 
    	

    					 
If no children are listed above are there plans for children in the future?     	
    	
How many children VISIT your home and what are their ages:							
    	
Have you filled out an application with other rescue organizations? If so, which ones?			
    	

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.										
    	

Cari Smith	 carimcsmith@yahoo.com	       4136 R Street     Omaha, NE       68107	   402-917-3070