Pookah's Pack Rescue Adoption Application
Contact Information
Name
First Name
Last Name
Spouses Name (if applicable)
First Name
Last Name
Age
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long at address?
Daytime Phone
-
Area Code
Phone Number
Evening Phone
-
Area Code
Phone Number
Best time to call
Occupation
Family & Housing
How many adults in the home and their relationship to you?
How many Children (ages)?
Occupancy Type
Own
Rent
Other
Type of Home
Single Family
Townhouse
Apartment
Other
If renting do you have landlords permission to have a pet?
Yes
No
Landlord's Phone Number (by giving this information you are allowing Pookah's Pack Rescue to contact your landlord. Please inform them of this call so they will speak to us.)
-
Area Code
Phone Number
Landlord's Name
First Name
Last Name
Do anyone in the family have a known allergy to animals?
I have a pet allergy
Someone in my home has a pet allergy
No pet allergies
Is everyone in your home in agreement with the decision to adopt?
Yes
No
Describe your household
Active
Noisy
Quiet
Other
Do you have adequate time to provide love & attention?
Yes
No
Other Pets
Do you have other pets?
Yes
No
If yes, please indicate: names, breed, gender, age, and any known medical issues. If none, mark N/A.
If you have pets are they kept indoors or outdoors
Indoors
Outdoors
Both
Are your pets up to date on vaccines?
Yes
No
N/A
If no, please explain why
Have you ever surrendered a pet? If so, why?
Have you ever had a pet euthanized? If so, why?
Have you ever lost a pet to an accident?
How do you discipline your pets and why?
Veterinarian
Do you have a regular Veterinarian?
Yes
No
Veterinarian's Name
First Name
Last Name
Clinic Name
Clinic Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Clinic Phone Number (By providing Pookah's Pack Rescue with this information you are allowing us to contact your vet. Please contact your vet and authorize the release of information to Pookah's Pack Rescue.)
-
Area Code
Phone Number
About The Dog You Wish To Adopt
What is your ideal dog and why?
Desired age
Desired size
Desired breed
Breed you would not adopt
Desired Sex
Spayed Female
Neutered Male
No Preference
Willing to adopt
Outgoing/Hyper
Dog that needs regular medication
Dog that needs grooming
Shy dog
Dog that needs training
None of the above
Where will the dog spend the day? (Describe)
Where will the dog spend the night? (Describe)
Number of hours (average) the dog will spend alone?
Who will have primary responsibility for this dog's daily care?
Who will have financial responsibility for this dog?
Do you agree to provide regular health care by a licensed veterinarian?
Yes
No
Do you agree to keep this dog as an indoor pet?
Yes
No
When the dog goes outside, how do you plan to supervise it? Fenced yard?
Do you agree to contact Pookah's Pack Rescue if you can no longer keep this dog?
Yes
No
Are you willing to allow a representative of Pookah's Pack to visit your home by appointment?
Yes
No
How did you hear about Pookah's Pack Rescue?
Would you be interested in fostering?
Yes
No
Would like to know more
Terms & Conditions
Do you agree to stay in touch and provide picture updates, as requested?
Agree
Disagree
I certify that I am at least 21 years of age and the information I have provided on this application is true. I also recognize that any misrepresentation or omissions may result in the loss of privilege to adopt from Pookah's Pack.
Agree
Disagree
I understand dogs are adopted to the best home and not on a first come, first serve basis. Even if I am applying for a particular dog, my application may be approved but a better suited home may be selected. I may be better suited for another dog that meets my needs.
Agree
Disagree
I understand that Pookah's Pack is not able to guarantee the health or temperament of any dog, as many dogs come from unknown histories. There are traits that could change upon adoption and I take responsibility to address these issues if they do arise.
Agree
Disagree
I understand that I am to immediately contact Pookah's Pack in the event that my adopted dog is lost/missing.
Agree
Disagree
I understand that anything can happen in life, and if I find that I am no longer able to care for my adopted dog, I agree to contact Pookah's Pack by phone and/or email to discuss return/or need for help of the adopted animal.
Agree
Disagree
I understand that Pookah's Pack has the right to deny any application for any reason.
Agree
Disagree
Personal References
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Address
Relationship (relative, neighbor, friend, etc.)
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Address
Relationship (relative, neighbor, friend, etc.)
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Address
Relationship (relative, neighbor, friend, etc.)
All of the above information I have given is true and complete. This dog will reside in my home as a pet. I will provide it with quality food, plenty of fresh water, indoor shelter, affection, annual physical examination and vaccinations under the supervision of a licensed veterinarian. Signature
Submit
Should be Empty: