Adoption Application TwitterPersonal 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 -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ====================AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Employer Zipcode * How long have you worked there? * Adoption Information Home Address * City * State * - Select Province/State -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ====================AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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 ApplicationBy 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 *