Home Phone Number:
Email Address (i.e. RottiesRule@aol.com):
Business Phone:
Business Phone:

Household Information

Number of Children: Their ages
What breeds of dogs have your children lived with? 
How long have you lived at this address? 
Which best describes your current home? (choose all that apply)
House |Condo |Apartment |Mobile Home
Rent | Own | Live with Parent
Please provide the name and phone number for your landlord (renters) or land owner (mobile home)
Please list all of the members of your household, yourself included, whether they are relatives or not. (name, age, relationship)?

Does your home have a yard?
Is it completely fenced?  Is gate padlocked? Is fence secure underground?

Foster Information

What provisions will be made for your pet when no one is home?

Do you prefer to foster a male or female dog?  Age Range? 

Current Pet Information

Do you have any pet(s) currently? List type, breed, age, & gender.

Tell us about the pets you have owned over the past 10 years, i.e. type of pet(s), how many years you owned them, reason for no longer owning them.

Veterinarian's Name & Phone Number. Please also tell us what name the pet is under at the vet's office.

Are your pets current on vaccinations? 
Are your pets spayed/neutered?
Are your pets on heartworm preventative? What brand?
When did you visit your veterinarian last? 

All of the dogs placed have undergone thorough temperament evaluations and have lived with foster families prior to their adoption.While in foster care, we begin training and work to resolve any behavioral obstacles before adoption. Generally we are only able to give you the dog's history from the time it enters our program. Are you able and willing to continue working on these challenges with us to ensure that your adopted dog is a respectable canine companion and family member? Your comments are encouraged.

Do you have a crate available for your foster dog?
Do you have time to continue this dog's training while in your care?

Please provide the name and contact information of two persons who have been to your home and interacted with you and your pets.

Reference #1 (name, relationship, evening phone number, email address):

Reference #2 (name, relationship, evening phone number, email address):

Additional Comments: 

I certify that the information I have provided on this form is true, correct, and accurate.I understand and agree that falsification of any of the above information is grounds to disqualify my adoption application and nullify all adoption(s) and/or adoption agreement . I understand that there is no obligation to place an animal to me, now or in the future. I understand that my electronically-generated signature [below] is valid as a means of legal signature for the purpose of this adoption application (Yes or No) :

Signature: Date: