First Name*
Last Name*
Address*
City*
State/Province*
Zip/Postal Code* -
Email*
Home Phone*
Cell Phone*
Age*
What is your occupation?*
Place of Employment?*
Why are you interested in adopting a pet at this time*
Are you considering other dogs, not in our rescue?
How did you hear about us*
Which animal are you interested in Choose an animal: Dina Tuck
What traits are you looking for in a pet
Please explain the daily activities of your home, and how the new pet will fit in?*
Do you own or rent your home* Choose one: Rent Own
If you rent, or live in a manufactured Community please enter your landlord's name and phone number*
If you rent, we will need to have an approval from your landlord. Choose one: Yes No
In what type of home do you live* Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing
Other adults in the home? If yes, give names and ages*
How many children are in the home, and what are the ages?*
How many people reside in your household*
Who in the household will care for the pet*
How much time will the animal spend alone during the day*
Do you have any other pets in the home? IF so, please describe them, Name, breed, weight and age..*
Is your current pet spayed or neutered?*
Where will the pet spend time when left alone in the home?*
Have you ever given up a pet? If yes, please explain*
Does anyone living in the home have any Pet Allergies?*
What reasons would you return a cat to us?*
We need the name and contact number for your Vet:*
Name and contact number of 2 personal references. And Best time to reach them:*
List at least two references (who is not a family member), and best time to reach them:*
If the dog, you applied for is no longer available please tell us which dog, you would be most interested in adopting? *
Are you willing to do Home visits* Choose one: Yes No
I certify that the information entered on this applicant is true. Enter your name and date*