Balanced Buddies Res-Q Adoption Application

Please list any particular dog you are interested in:

Full Name*

First NameLast Name

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number - Home

Area CodePhone Number

Phone Number - Cellular

Area CodePhone Number

Do you live in a:*

OwnRentLive with ParentsOther

If Renting: Please indicate landlord contact information. (Renters must provide a letter from your landlord stating you are able to have the type of pet you are looking to adopt.)

How long have you lived at this residence?

YesNoPartial

If fenced, please give details on height, material, # of gates, are gates locked or lockable?

Is everyone in your household aware of and on board with your intentions to adopt a dog?

Occupation & Work hours.

Busy/NoisyModerate Comings/GoingsQuiet with Occasional Guests

Please List all People Living in the Household (Include Name, Relationship, Gender and Age)*

YesNo

YesNoIf yes, please explain why.

YesNoIf no, please explain why.

Please List any Pets you have Living or Deceased (Please include Name, Breed, Age, spayed or neutered, Sex, UTD Vaccines, Heartworm, Living/Deceased)

How do you discipline and house train your current pets?

If/when you travel how will you provide for the dog while you are away?

YesNo

Veterinarian Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Reference Name & Phone Number

First NameLast Name

Phone Number

Area CodePhone Number

Reference Name & Phone Number

First NameLast Name

Phone Number

Area CodePhone Number

*Please let your references know that we will be calling, so they are not surprised to receive a call from an unknown phone number.

YesNo

YesNoIf so, what is the limit?

If so, what is the limit?

How many hours in a day would the dog be left alone?*

Under which of the following circumstances would you not keep the dog? Divorce Moving New Baby New Job Potty- training problem Chewing furniture /carpet/drapes Biting people Fleas Allergy Shedding Conflicts with Children Conflicts with other pets Dog became ill High veterinary costs None of the above if Other (please explain):

Have you ever had to give up or euthanize a pet? If yes, please explain.

Behavior

From the list of characteristics below, please list those that are most important to you:

____kid friendly ____sleeps in dog bed

____dog friendly ____sleeps in your bed

____cat friendly ____shy/timid

____outgoing ____loner

____leash trained ____potty trained

____crate trained ____likes car rides

____small size ____mostly quiet

____larger size ____cuddler

Please list important characteristics:

*What other rescues or shelters have you applied to in the last six months?

Please add any other comments you may have in regards to adopting this pet.

Please be advised, if we are able to move forward with the home visit we will require a copy of your drivers license or another valid form of identification.

All dogs will be spayed/neutered prior to adoption.

This application is a not binding agreement. Applicant is under no obligation to adopt a dog, and Balanced Buddies Res-Q is under no obligation to provide a dog to applicant. Dogs suggested to the applicant based on this application and the subsequent interview and home check may differ from dogs listed on this application, as Balanced Buddies Res-Q may believe that different dogs are a better match for said applicant.

By sending this electronically, I acknowledge that I have completely read this questionnaire and comprehend it fully.

I understand that applying does not ensure approval and that untruthful answers or failure to comply with the requirements of this application can result in the forfeiture of any Balanced Buddies Res-Q animal.

I certify that the above information is correct, and I understand that the information will be verified.

I understand that by submitting this form electronically, I agree to release and covenant to hold harmless Balanced buddies Res-Q and it's members from any claims, damages, costs, or actions incurred because of the care or actions of the foster dog.

I accept full responsibility for the dog(s) actions at all times, and release Balanced buddies Res-Q from any liabilities or damages that may be incurred because of fostering such dog(s).

I agree to have Balanced buddies Res-Q complete reference call checks and conduct a home visit inspection to be able to approve my foster application.

I agree that if I'm unable to foster the dog(s) anymore that I will return the dog(s) to Balanced buddies Res-Q and try to give Balanced buddies Res-Q a 2 week period to try and find another suitable foster for the dog(s).

Date*

MonthDayYearHourMinutesAM/PM Option

Your name*

Co-Applicant name (if applicable)

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