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.

CellLandline

Alternate Phone number

Please enter a valid phone number.

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

Include Last names and ages

Is anyone allergic to Animals?*

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: gender, breed, age, personality.*

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 *

Vet's Phone number

Please enter a valid phone number.

Reference #1 Full Name/Relationship*

FIRST AND LAST NAME

Reference #1 Phone Number*

Please enter a valid phone number.

Reference #2 Full Name/Relationship*

FIRST AND LAST NAME

Reference #2 Phone Number*

Please enter a valid phone number.

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

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

Please provide two personal references