Pet Refuge, Inc. Dog Application Form (adoptions are subject to 48 hour waiting period)

Date____________________

Dog Name__________________

Applicants Name_________________________Address_______________________________

City_____________________State_______ Zip Code____________

Phone Number w/area code (______)_____________

Place of Employment_____________________________Address_______________________________

City_____________________State_______ Zip Code____________

Phone Number w/area code (______)_____________ Do you work full time?__ part time?__

(check one)

Spouse Name________________________________________

Place of Employment________________________________Address_________________________________

City_____________________State_______ Zip Code____________

Phone Number w/area code (______)_____________ Do you work full time?__ part time?__

(check one)

Do you rent or own your home? RENT OWN What Type? HOME TOWNHOUSE

(circle which applies) CONDO APARTMENT

MOBILE HOME LIVE W/RELATIVE

If you rent, Landlord name and phone number______________________________________

How long have you lived at this address?_______________________

Are you planning on moving in the next year? YES NO

Are you considering adopting -- (circle which applies): ADULT DOG (Over 1 years)

ADOLESCENT (4 months to 1 year) PUPPY (2-4 months)

Where will this dog be kept during the day?________________ At night?________________

When left alone?_______________________

How many hours a day will this dog be left alone without human companionship?________

Do you travel often? YES NO If so, how will you provide for the dog while away?

___________________________________________

How many people live in your home?________Adults?_______Children?_______ Ages:_______________

Will this be your children’s first experience with a dog or a puppy as part of the

household? YES NO

Does anyone in your household have allergies to animals? YES NO

If yes, what type of allergy?_______________________________________

What would you do if someone in the household became allergic to the dog after you adopt

it?__________________________________________________________________________________

Are you familiar with crate training? YES NO

Would you crate this dog if it was necessary? YES NO

How do you plan to contain this dog?____________________Do you have a fence? YES NO

If yes, how high is it?______________ Type of Fence?______________________

How do you intend to train this dog?_________________________

How do you plan to exercise this dog and how often?____________________________________

Do you currently own pets? YES NO

Breed Name/Age Sex (neutered?) Shots current? Vet Clinic Name

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

(use back of form for additional listings)

Last Vet Visit (month/year)____________________

If you presently do not own a dog, have you owned one before (within last 7 yrs) YES NO

What became of your dog?_____________________________________________________

Is this pet to be a gift? YES NO Who is the gift for?______________________

Who is responsible for the care of this pet?______________________________________

Are all members of your household aware of you're adopting a pet? YES NO

Have you applied for or adopted a pet from Pet Refuge or any other Shelter? YES NO

When?__________________ Where?_________________

Have you ever turned an animal into a Shelter? YES NO

If yes, what were the circumstances?___________________________________________________

Do you understand that all household pets need to go to the Veterinarian on a yearly basis for shots and a checkup? YES NO

Who will be responsible for the care and cost of this dog?_______________

Are you prepared to incur the many expenses involved in owning a pet? (Veterinary expenses, food, toys, training, yearly license, grooming and boarding fees) YES NO

Please list the estimated cost per year of owning a pet_________________________________

Are you aware that some shelter animals have unknown medical backgrounds? YES NO

Are you prepared to provide and pay for necessary treatment? YES NO

Are you familiar with canine heartworms? YES NO

Do you plan to have this dog on heartworm preventative? YES NO

Dogs can live 15 years or longer. Can you commit to caring for this dog for that period of time? YES NO

Do you fully understand the responsibility this adoption will entail and are you willing to take on this responsibility? YES NO

Please list two personal character references (if you currently own pets, you may use your

Veterinarian as one of your references):

(name, address, phone number)

1._______________________________________ 2._____________________________________

_________________________________________ ______________________________________

What would make you want to return this dog or puppy?________________________________

In signing this form, I confirm that the above statements are true and factual.

___________________________________________________ __________________________

Signature of Applicant Date

*Pet Refuge is an all-volunteer, non-profit organization. WE RESERVE THE RIGHT TO

DETERMINE THE APPROPRIATE HOME FOR EACH DOG. In addition, we will require photo ID.

To help us better use our resources, please tell us how you learned about Pet Refuge -- circle all that

apply:

RADIO TV NEWSPAPER WEBSITE FRIENDS PRIOR EXPERIENCE

OTHER:_________________________________

~Thank you~

*************************************************************************************

Office Use Only:

Interviewer Initials_____________ Approved__________ Denied_______________

Comments___________________________________________________________________________

Interviewer Initials_____________ Approved__________ Denied_______________

Comments___________________________________________________________________________