Adoption Application Company Personal Information Your Full Name * Spouse's Full Name (if applicable) Phone Number * Email Address * Number of Children in Your Home * Ages of Children Are there any others residing in your home? * Yes No If yes, please list. Employer Name * Job Title * Supervisor's Name * Employer Phone * Employer Address * Employer City * Employer State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Employer Zipcode * How long have you worked there? * Adoption Information Home Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zipcode * Number of years at this address? * If less than two years, what was your previous address? * Is this where your pet will live with you? * Yes No If no, where will you and your pet live? What type of residence is this? * Apartment House Condo Mobile Home Do you rent or own? * Rent Own If you rent, please provide your landlord's name & telephone number. If you rent, do you have your landlord's permission to adopt a dog? Yes No If you move, what do you plan to do with your pet? * Residential Information What do you think makes this particular pet a good choice for you? * What experience, if any, do you have with this particular breed of dog? * Do you have a fence around your yard? If so, please describe. * How will you exercise your pet? * How many hours are you away from home during the average work day? * Where will your pet be kept during that time? * Where will your pet sleep at night? * What kind of other pets do you have at home? Please list types/ages/sexes. * Are they all current on their vaccinations? * Yes No Your Veterinarian's Name * Veterinarian's City * Veterinarian's Phone * Does anyone in the household have allergies? * Yes No Does anyone in the household have Asthma? * Yes No Have you, or anyone in your household, been convicted of animal cruelty, neglect, or abandonment? * Yes No Have you ever had to give up a pet? If so, please explain. * Is there anything else you would like to add? References Reference #1 * Reference #2 * Reference #3 * Reference #1 * Reference #2 * Reference #3 * Submit Your Application By entering my name below and clicking "submit" I certify that all information provided on this form is true. I give permission to Rescuer to verify information as needed. I understand that a home check may be mandatory prior to adopting a pet. Any false statements made will terminate potential adoption. Enter Full Name * Today's Date *