Wiggle Butts Rescue, Inc. Adoption Application

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

Phone Number

Area CodePhone Number

What is the best time to contact you?

Occupation

Name of dog you would like to adopt

Why this Dog?

Where did you hear about the dog you are applying to adopt?

Please indicate the reasons for wanting to adopt this pet (please check all that apply)

CompanionWatchdogFamily PetOther

How long wil the pet be alone in a 24 hour period?

Do you live in a

HouseApartmentCondoMobile

Do you

OwnRent

If you rent does your landlord allow pets?

YesNo

Are there any breed, weight restrictions?

YesNo

May we contact your landlord?

YesNo

Name and number of landlord/leasing office

Do you have a fenced yard?

YesNo

Please describe the fence

Do you have a pool?

YesNo

Are there children in your home?

YesNo

Children's names and ages

How many people including children live in your home?

Where will your pet spend most of his/her time?

Where will your pet sleep at night?

Where will your pet be when you are not at home?

What arrangements will be made for your pet when you travel?

Do you currently own any other pets?

YesNo

If you answered "Yes", please provide Name, Breed, Age and if they are spayed/neutered.

Have you had any other pets in the last 5 years?

YesNo

If you answered "Yes" what happened to them?

We don't always know if a pup is houseborken. Are you willing to potty train if they are not?

YesNo

Are you willing to commit to a training class/program if this pup needs it?

YesNo

If your present living conditions were to change (move,divorce, loss of job, ect.) what would you do with your pup?

Under what circumstances would you feel it necessary to give this pup up?

Have you ever surrendered a pet to the humane society or shelter?

YesNo

If "Yes" please explain circumstances.

Have you ever been convicted of animal cruelty or neglect?

YesNo

If "yes" please explain the circumstances.

Any animal related violations?

YesNo

If "yes" please explain circumstances.

Have you ever been denied pet ownership from a rescue organization or shelter?

YesNo

If "yes" please explain circumstances.

May we contact your veterinarian?

YesNo

Name and phone no. of your current veterinarian

May we visit your home to do a home check?

YesNo

Please read and initial below.

All of the information I have provided is true and complete to the best of my knowledge. I understand that it is my decition whether or not to any particular pup. I will not hold Wiggle Butts Rescue, Inc. responsible for any damage, injury, or harm caused directly or indirectly to any person or property by any pup I decide to adopt.

WIGGLE BUTTS RESCUE, INC. AT IT'S SOLE DISCRETION RESERVES THE RIGHT TO REFUSE ANY APPLICANT FOR ANY OR NO REASON.

I have read the disclaimer and agree to these terms and conditions.

By typing in my name, I am legally responsible for agreeing to these terms and conditions.

MonthDayYear

Full Name

First NameLast Name