Adoption Application

Animal You Want To Adopt?*

Your Name*

First NameLast Name

Name used on social media?*

Date of Birth*

Date

Primary Phone number*

Please enter a valid phone number.Format: (000) 000-0000.

*

CellLandline

Alternate Phone number

Please enter a valid phone number.Format: (000) 000-0000.

CellLandline

E-mail*

example@example.com

Address*

Street Address

*

City, State, Zip code

Type of Residence:*

HouseApartmentCondo/TownhouseMobile Home

How long at present address?

*

RentOwn

If Renting, provide landlord's name and phone number (or enter n/a)*

What is your source of income/what is your job?*

Please list full name and age of each person living in household, starting with yourself:*

Include Last names and ages

If you are active duty military/military reserve or travel for work, who will take custody of the dog while you are detached, deployed or on extended travel for work related trips? *

Name, phone number

In the event of an emergency and you are no longer able to take care of the dog who will take custody of the dog? Name and phone number of person. * please note we would need to be contacted as well in the event you are unable to care for your dog*

Name, phone number

Is anyone allergic to Animals?*

YesNo

Does everyone in the household know and in agreement to adopt a new furry friend?*

YesNo

Have you adopted an animal before?*

YesNo

If yes, from which organization

Is your yard fenced?*

YesNo

How tall is the fence?*

4 feet6 feet8 feetNone

Type of Fence*

If other, please explain what type

Are there currently dogs in the home*

YesNo

Where do they primarily live?*

IndoorsOutdoorsBothN/A

Please list all dogs in the home and give a short description of each: name, gender, breed, age, personality.*

If no current animals, please list name and breed of animals from past 3 years, but notate no longer with you

Do you have cats:*

YesNo

If yes, do they live:

IndoorsOutdoorsBothN/A

Do you have:

ChickensLivestockOther AnimalsNone

Are all of your pets spayed & neutered*

YesNo

If no, please explain why:

Is your pet on heartworm and flea prevention?*

YesNoN/A

If yes, what kind? If no, why not?*

Have you ever given up a pet before? If yes, please explain the circumstances*

How many hours a day will your new pet be left alone?*

Where will your new pet stay when left alone?*

Where will your new pet sleep at night?*

How will you handle potential behavior issues with your pet? *

Barking, House accidents, Chewing, scratching

Will your new pet be allowed on the furniture? If not why? And how will you keep them off?*

Vet's Name and name account is under:*

Current Vet's Phone number (you may want to call ahead of time and advise them we will be calling and give permission for them to speak with us as a reference)*

Please enter a valid phone number.Format: (000) 000-0000.

Name of Previous vet if you have recently switched and Name account is under:*

Previous Vet's Phone number*

Please enter a valid phone number.Format: (000) 000-0000.

Reference #1 Full Name/Relationship*

FIRST AND LAST NAME

Reference #1 Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Reference #2 Full Name/Relationship*

FIRST AND LAST NAME

Reference #2 Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Any other comments or information you would like us to know in considering your adoption application?

*please note we will be communicating with you through email so keep an eye on your inbox and spam folder.

I affirm to accuracy of data entered

Type full name here

I have read the above information carefully and have filled out this application honestly. I understand that omission of information and/or failure to answer all questions and sign the application can result in this application being declined. Also, if an omission or untruth is discovered after an adoption takes place, I understand Rosalie and Friends reserves the right to annul the adoption and reclaim the animal. I give Rosalie and Friends permission to fully investigate the information provided as well as contact veterinarians and related officials. If the application passes this review, I agree to a home and yard visit on a mutually agreed date by a Rosalie and Friends volunteer before an adoption decision is made.

In addition, I understand the adoption decision is dependent on many factors, including but not limited to the compatibility of the family and home to the individual animal, and other applications received on this animal. I understand it is the Rosalie and Friends prerogative to decide which home is most appropriate and that their decision is final, and therefore I will not argue with the decision. Unless otherwise indicated by Rosalie and Friends, I am free to apply and undergo the application process in the future.

Date*

Date

Adoption Application: Rosalie and Friends

Please provide two personal references