Midwest Small Breed Rescue

Midwest Small Breed Rescue Application
Date

MonthDayYear
Date
Name
E-mail
Age

Under 2121-2930-3940-4950-5960-6970+
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Alternative Phone Number

Area CodePhone Number
Alternative Phone Number

CellHomeWork
Employer
Which animal are you interested in?
Why are you interested in adopting this dog?
On a scale of 1 (low energy) to 5 (high energy)...what activity level are you looking for?

12345
Do you currently own any pets?

YesNo
If yes, please list BREED/AGE/SEX:
Are your current animals up to date on all shots?

YesNo
Are your current animals spayed/neutered?

YesNo
If not, explain the reason that they are not spayed/neutered:
Have you ever given a pet away?

YesNo
If yes, explain your reason:
Please list any past pets (not already mentioned) and what happened to them: If none, type "none."
How long do you plan on keeping this dog?:
Under what circumstances would you give this dog up?
Current/Past Veterinarian: If none, type "none."
Phone Number of Veterinarian

Area CodePhone Number
Name account is under
Approximate date/reason of last Veterinarian visit:
Do you live in a:

HouseCondoApartmentMobile HomeDuplex
Social Environment

CitySuburbsCountry
Do you own or rent?

OwnRent
How long have you lived at this address?
If you rent, do you have your landlord's permission to have a pet?

YesNo
If you rent, provide name of Landlord: (We will contact your landlord to verify that your lease allows for pet ownership.)
Landlord's Phone Number

Area CodePhone Number
Do you have a fenced yard?

YesNo
What is type and height of fence?
If no fence, how do you plan on taking the dog outside to exercise and potty?
How many adults in your household? What is relationship to applicant?
How many children in your household? (List ages)
Do you have young children visit your home on a regular basis (i.e., grandchildren, babysitting, etc.)

YesNo
Is everyone in your home agreeable to adopting a rescue dog

YesNo
Where will dog spend most of his/her time? Give details.
How many hours will dog be home alone during the day?

0-12-34-56-78-910+
Where will dog stay when home alone? Give details.
Do you understand that even though a dog may be housebroken in their foster home, when they move to a new environment there is an adjustment period where they may have accidents in their new home? Housebreaking techniques will need to be utilized.

YesNo
What type of potty training methods will you use? (Give details)
Will you be willing to work with us to correct any possible behavior problems that develop after adoption?

YesNo
Are you physically able to care for a dog? If limitations, please explain.
I understand that proper food, grooming and veterinarian care may be costly and I am able and willing to meet the needs of my adoptive dog.

YesNo
I grant Midwest Small Breed Rescue permission to conduct a home check.

YesNo
Are you planning on enrolling the dog in obedience class?

YesNoIf needed
Do you have any additional information you would like to provide?
I understand by submitting this application, I am declaring that the information I have provided in this application is complete and correct.

YesNo
Should be Empty:

Midwest Small Breed Rescue Application