Form

Full Name *

First Name Last Name

E-mail *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number

Employer

Employers Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Work Number *

- Area Code Phone Number

Which Dog are you interested in? *

Why did you select this Dog? *

Where did you hear about this Dog? *

Adoption Event Website Pet Finders Friend

Please indicate reason for wanting to adopt this dog. *

Companion Watch Dog Family Pet Gift Other

Do you live in a *

House Apartment Condo Mobile Home

Do you Own Or Rent? *

Own Rent

If you Rent, Does your lease permit Dogs? *

Yes No I don't know

Are there Restrictions? *

May we contact your landlord? *

Yes No

Name of Landlord

Phone Number

- Area Code Phone Number

Do you have a fenced back yard? *

Yes No

If yes, is your yard fence secured? *

Yes No

Do you have a pool? *

Yes No

Is there a fence around the pool? *

Yes No

How long have you resided in your home? *

Please Check all that apply *

Busy Household-children, in and out alot,visits by friends Noisy-TV, Stereo, Machinery, Tools, Children playing, Dogs Barking Moderate-Normal Coming and Going Quiet-Homebodies, Come home, Stay Home Lots of Children in the Neighborhood Live on a busy street

Are there any children in the home? *

Yes No

If so, Names and Ages, Female or Male?

How many people are living in the home, including yourself? *

Do you or any family member have allergies to dogs? *

Yes No I don't know

Are all family members aware you are adopting a dog? *

Yes No

If yes, do they approve?

Yes No I don't know

Where will the dog be kept most of the time? *

Crate Indoors Outdoors Garage Patio/Porch Other

Where will your dog be sleeping? *

Crate Pet Bed With Owner Designated Room Outdoors Garage Patio/Porch

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

Outside Inside Crate Other

What will he/she do for excercise and potty breaks? *

Who will be responsible for feeding and caring for the dog? *

How long will the dog be alone in a typical 24 hour day? *

How much money do you plan to spend on the dog in an average year for medical care? *

What arrangements will you make for your dog while you are travelling? *

Do you currently have any pets? *

Yes No

If so, Name, Breed, Age

Check all that applies

Up to date on Vaccines Spayed/Neutered Not Up to date on Vaccines Not Spayed/Neutered

Are they on any flea medication?

Yes No

Are they currenty licensed in your county?

Yes No

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

Yes No

If so, what happened to them? (given away, passed away, ran away, accident?)

We don't always know if a dog is potty trained. Are you willing to potty train your pet? *

Yes No

Do you have any experience with the following? *

Crate Training Obedience Training Raising a Litter Modifying Behavioral Issues Potty Training

Please list any other experiences that you feel will be beneficial in adopting one of our dogs.

Are you willing to commit to a training class/program if needed? *

Yes No

Please check types of confinement you can provide. *

Crate Fenced Yard Kennel Run

How long are you willing to allow time for bonding? *

One Week Two Weeks One Month

If your present living conditions were to change (job, move, divorce, etc.) what arrangements will you make for your dog?

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

Dog Barks or Whines Dog has potty accident in the home Dog damages property Dog becomes aggressive Dog becomes very ill You move to another state

Have you surrendered a pet to the Humane Society or Shelter? *

Yes No

If "Yes" please explain.

Have you ever been convicted of animal cruelty or neglect? If so, please explain.

Any Animal Violations? If "Yes", please explain.

If your pet went missing, what would you do?

Have you ever been denied pet ownership from a Rescue Organization? *

Yes No

Please provide 3 references that we may contact. Include Name, Phone No. and realtionship. *

May we contact your Veterinarian? *

Yes No

Name of Veterinarian

First Name Last Name

Phone Number

- Area Code Phone Number

Would you object to a home visit by one of our representatives? *

Yes No

If "Yes" please explain.

I agree to the terms as stated above. *

Agree Disagree

Please enter today's date. *

- Month - Day Year

IMPORTANT! Please read the following: All of the information I have provided is true and complete to the best of my knowledge. I agree to follow the rules and policies of Leashes of Love Rescue, Inc. I understand it is my decision on whether to adopt a dog or not. I will not hold Leashes of Love Rescue, Inc. responsible for any damage, injury or harm caused directly or indirectly to any person or property by any dog I may decide to adopt. LEASHES OF LOVE RESCUE, INC. AT ITS SOLE DISCRETION, RESERVES THE RIGHT TO REFUSE ANY APPLICANT FOR ANY OR NO REASON.

Leashes of Love Adoption Application