ADOPTION APPLICATION
Full Name
*
First Name
Last Name
E-mail
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
*
-
Area Code
Phone Number
Best time to call
*
Alternate Phone Number
-
Area Code
Phone Number
Best time to call alternate phone
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Occupation
*
Spouse
Spouse's Occupation
PERSONAL REFERENCES
(Please provide three.)
1. Reference Name
*
Phone Number
*
-
Area Code
Phone Number
Relationship
*
2. Reference Name
*
Phone Number
*
-
Area Code
Phone Number
Relationship
*
3. Reference Name
*
Phone Number
*
-
Area Code
Phone Number
Relationship
*
RESIDENCE INFORMATION
Type of Dwelling
*
Please Select
House
Mobile Home
Duplex
Condo
Apartment
How long at this address?
*
Do you own or rent?
*
Please Select
Own
Rent
Previous address if less than 2 years.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
If renting, do you have your landlord's permission to own a dog?
Please Select
Yes
No
Landlord's Name
First Name
Last Name
Landlord's Phone Number
-
Area Code
Phone Number
CONTAINMENT INFORMATION
Do you have a fenced yard?
*
Please Select
Yes
No
If yes, check all fence types that apply:
Chain Link
Privacy
Invisible
Other
If other, please specify:
Fence Height
under 4'
4'
5'
6' or more
If you do not have a fenced yard, how do you plan to handle exercise and toilet duties?
Are you familiar with crating?
*
Please Select
Yes
No
What do you think about the use of crates?
*
HOUSEHOLD INFORMATION
Are there people other than the applicant living in the household? If yes, please provide the following information for each person:
Please Select
Yes
No
First person:
1. Full Name
First Name
Last Name
Age
Relationship
Occupation
Second person:
2. Full Name
First Name
Last Name
Age
Relationship
Occupation
Third person:
3. Full Name
First Name
Last Name
Age
Relationship
Occupation
Fourth person:
4. Full Name
First Name
Last Name
Age
Relationship
Occupation
Fifth person:
5. Full Name
First Name
Last Name
Age
Relationship
Occupation
More persons not listed above?
Please Select
Yes
No
If yes, please identify them:
Dog's primary caregiver:
*
Has everyone listed above agreed to your pursuing adoption?
Please Select
Yes
No
PET OWNERSHIP
Have you ever owned any dogs?
*
Please Select
Yes
No
If yes, how many in the past ten years?
Briefly describe what happened to the dogs you no longer have:
How many do you own now?
(Leave blank if none.)
For each dog you currently own, provide the following information:
1. Name
Age
Breed
Spayed/Neutered
Please Select
Option 1
Option 2
Option 3
Sex
Please Select
Male
Female
2. Name
Age
Breed
Spayed/Neutered
Please Select
Option 1
Option 2
Option 3
Sex
Please Select
Male
Female
3. Name
Age
Breed
Spayed/Neutered
Please Select
Yes
No
Sex
Please Select
Male
Female
4. Name
Age
Breed
Spayed/Neutered
Please Select
Option 1
Option 2
Option 3
Sex
Please Select
Male
Female
5. Name
Age
Breed
Spayed/Neutered
Please Select
Yes
No
Sex
Please Select
Male
Female
More dogs not listed above?
Please Select
Yes
No
If yes, please identify:
Do you have any other pets?
*
Please Select
Yes
No
If yes, please list all animals that you own (other than dogs):
Do you walk your dog(s)?
Please Select
Yes
No
How often do you walk your dog(s)?
Please describe any other activities you do with your dog(s):
VETERINARIAN INFORMATION
Do you have a veterinarian?
*
Please Select
Yes
No
If yes, please provide the following information:
Name of veterinarian:
Name of organization:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
-
Area Code
Phone Number
E-mail
Are you familiar with heartworm disease?
*
Please Select
Yes
No
Do you currently practice heartworm preventative?
Please Select
Yes
No
If yes, what medication do you use and how often?
ADOPTION INFORMATION
This application is for:
*
Please Select
Adoption
Fostering
Is this for a specific dog?
*
Please Select
Yes
No
If yes, the dog's name:
Your preferences:
Breed
Sex
Please Select
Male
Female
Age
Why you prefer this breed:
Would you consider a mixed breed?
Please Select
Yes
No
Dog's energy level. (Check all that apply.)
Quiet
High Energy
Couch Potato
Athletic
Adventurous
Lap Dog
Spunky
Outdoorsy
Very Affectionate
Personality traits you are seeking in your new dog:
*
Please answer the following regarding your new family member.
Will you walk your new family member?
Please Select
Yes
No
How often will you walk your new family member?
Describe any other activities you will do with your new family member:
Attend obedience classes?
*
Please Select
Yes
No
What would you do if your dog bit someone?
*
THE NEW DOG
Where will your dog spend the day? (Check all that apply.)
Loose indoors
Garage
Outside in kennel run
Loose outdoors
Tied up outdoors
Crate
Basement
Other
If other, please explain.
Where will your dog spend the night? (Check all that apply.)
Loose indoors
Garage
Outside in kennel run
Loose outdoors
Tied up outdoors
Crate
Basement
Other
If other, please explain.
How many hours will your dog spend alone each day?
*
Is there someone home during the day?
*
Please Select
Yes
No
What are your work hours?
*
Who will care for your dog when you are on vacation?
*
OTHER INFORMATION
Will you allow a representative of Roughneck Rescue to visit your home by appointment?
*
Please Select
Yes
No
How did you hear about Roughneck Rescue?
*
Please let us know if there is any other information that you want us to consider when evaluating your application.
You understand that owning a dog is a commitment for the dog's lifetime and that if you adopt a dog from Roughneck Rescue, you are affirming that you are both willing and able to make that committment and that you can responsibly and reliably ensure the safety and welfare of the dog. I agree with the above statement.
*
Please Select
Yes
No
Please click the SUBMIT button.
Submit
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