Date:
Pet Interested In:
1. Name of Applicant:
2. Applicant Address. Please provide Street Address, City, State, Zipcode
4. Home Phone:
5. Email Address:
6. Employer and address and phone:
7. Occupation:
8. Number of Children Living in this household. Give Names and Ages: Number of Adults living in this household. Give Names, ages, and Occupations:
Is anyone living in this household either pregnant or trying to become pregnant?
9. What type of environment do you live in? Rural Suburb City
10. What kind of housing do you live in?Apt House Mobile Home
11. Do you rent or Own?
If you rent, do you have permission from your landlord to own a companion animal?
A pet that is under 25#
What is your landlord's name, address, and phone number?
12. What other dogs/cats have you previously owned and what happened to them? (state pet's name, age, if spayed/neutered, reason for giving up/cause of death):
What other dogs/cats currently live in your home: (please list: names, breed, sex, age, any health issues they may have & if spayed/neutered):
13. Are there any other types of animals currently living in your home? (if so, describe):
14. What do you know about the breed in question? ( It is required that you research this breed's traits/habits)?:
15. Are there any specific habits/problems you are not willing to work with? If so, please specify:
16. Gender Preference:
17. Do you have a fenced-in yard & is it connected to the house? (entire yard, front yard only, backyard& attached to back door, etc):
What is the height & dimensions of the fenced-in area (please, be specific, as this info is REQUIRED & PERTINENT to the approval of your application):
Please, describe your fencing materials(chain link, wooden stockade, vinyl rail...2, 3 or more rails.
Is it reinforced with wire./what kind of wire? wire...chicken/field/hog....or upright slats...etc).
What type of gates (describe as you did in above question):
Can they be opened by children?
If you don't have a fenced-in yard, how will the animal be exercised and allowed to eliminate?
18. Who will supervise outdoor activities?
19.Do you have a: Pet door, Kennel run, Dog house, Stake, Tie-out or cable-run,Crate, or None. Please describe in the box below:
20. Do you have a swimming pool?
Is it fenced-in separately from the rest of the yard?
21. What member of the family will be taking the MAJOR responsibility for the care of this animal?
22 Does anyone in your family have allergies to ANY animal?
23 Has anyone in your household had a problem with impulse control? Please explain:
24 What are your plans for this animal? Protection/guard, companion, child's pet, pet therapy, agility/fly ball, obedience, herding, ranch work, other? Please describe:
25 (a) Have you ever trained a dog in obedience classes?
(b) Are you planning on taking your adopted dog to an obedience class?
26 Have you ever sold, given away or surrendered a pet? If so, please provide details of situation: 27 (a) How much time are you willing to give the dog to adjust to it's new environment & family members?
(b) This dog may not be housebroken. Are you willing to take the time to work with the animal? (c) Do you understand that if this dog is any kind or variation of a hound breed, you will need to have a securely fenced-in yard or promise to keep the dog on a leash at all times whenever it is outdoors?
28. Will the animal live in the home? If not, where will it live?
29 What type of shelter will be provided when the dog is outside (doghouse/patio/decking overhang, etc):
30 Where, exactly, will the animal sleep at night and be kept when there is no one at home (i.e.., crated, free roam of home, laundry/kitchen area, fenced-in yard, etc):
31 (a) On the average, how long will the animal be left alone during the day?
(b) What is the activity level of your household? Busy, visits by friends, meetings, children, parties at home, noisy-TV, stereo, machinery, tools, kids playing; moderate-normal comings and goings; quiet-homebodies, few guests. Please describe in the box below:
32 Do you believe in dog crates? If so, for what exact purpose(s)?
33 If you had to move & your new landowner does not allow pets, what will you do with your companion animal?
34 When you go on vacation, will your pet accompany you or who would care for it?
35 Under what condition(s) would you consider giving up your companion animal?
36 (a) who is the veterinarian you currently use, or used for your previous animal's health issues (IF used within past 5 yrs)? Please provide the veterinarian's/Pet Hospital's name. address. and phone number:
(b) What type of Heartworm Prevention do you use?
37 (a) How will your animal travel to the vet, or other places(i.e.,crated, doggie seatbelt, loose in a car/van, tethered or in crate or in box in bed of truck?
37 (b) Are you willing to allow an RCHS's representative to periodically visit your home? If not, why?
40 List names, addresses, phone numbers & email addresses of 3 NON-RELATED personal references, whom you have known for at least 3 years, and who may be familiar with your pet ownership history:
40 (a) Reference 1
40 (b) Reference 2
40 (c) Reference 3
41 If you are disabled and should have any special needs please be sure to let us know; this will help us find the BEST companion for you and your needs:
42 What arrangements have you made for your companion animal(s), if you could no longer care for them (i.e.., moving overseas, extended hospital stay, nursing care facility, death)?
43 And, finally, please tell us a little about yourself and why you feel you could provide a good home for a rescued companion animal:
****Our goal in rescuing and re-homing animals is to provide them with a loving home for the rest of their lives. The adoption fee covers some their medical costs associated with the animal, medical and daily care during their foster period and any special care.
Signature
Signature of Spouse _Partner