Adoption Form

DIXIES REDEMPTION ANIMAL RESCUE

Vision. Mission. Compassion
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long at this address?:
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Name and Address of Employer:
Work Phone Number

Area CodePhone Number
Up until what time of night can we contact you via phone?
E-mail
Are you able to afford the adoption fee of up to 300? Adoption Fee depends on species. Contact us if you have any questions
How were you referred to us?
Are you planning on moving within the next 6 months?
If yes, what are your plans for your pets if you move?
Are you 18 years of age or older?
Birth Date

MonthDayYear
Do you own your own home?
If no, name and phone # of landlord:
Type of Dwelling:
Name and age of ALL occupants in household (including yourself):
If no children, do you plan on having children or will children be visiting the household frequently?
What is your reasoning for adopting a new pet?
How many total hours will your new pet be left alone during the day?
Do you have all the proper essentials for your new pet? If you need help please let us know and we can advise you on what to get.
Are any members of your household allergic to animals?
If yes, please describe:
Who will have chief responsibility for the care of your new pet?
Over the past 5 years, how many pets have you owned? (Include current pets)
List each pet individually including breed, species, age, still living with you?
If you currently own a dog or cat, how does he/she react to new animals?
Are your present pets up-to-date on their annual vaccines?
If no, please explain:
Are your present pets spayed or neutered?
Which animals on our website are you interested in? If not on website what species are you looking for?
Who is your current or most recent veterinarian?
Is your entire immediate family in agreement with the decision to bring a new pet into your home?
If anyone is NOT, please explain:
Have you or any member of your household ever been charged with cruelty to animals or negligence in animal care?
Please provide 2 personal references (only 1 can be a relative) that can testify to your responsibility and ability to care for your animals. This is required or your application cannot be approved. PLEASE BE AWARE: If your references are not easily reachable or do not reply in a timely manner, it will delay your application. If multiple references do not reply, your application will be filed on HOLD. Please choose your references carefully and be sure to list the correct contact numbers.
Reference #1
First and Last Name & Relationship to Self
Reference # 1 Phone Number

Area CodePhone Number
Reference #2
First and Last Name & Relationship to Self
Reference #2 Phone Number

Area CodePhone Number
If there is anything else you think we should know, please note it here.
Thank you so much for wanting to rescue! You are making a difference!
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DIXIES REDEMPTION ANIMAL RESCUE

Thank you so much for wanting to rescue! You are making a difference!