First and Last Name:
I am interested in the following: (click all that apply)
Are you interested in a specific dog we have on our site? If so list the name of the dog.
Town, State and Zip Code:
Home, Work and Cell Phone Numbers:
What is your age? (Do not leave blank)
Name, age and occupation of spouse or significant other. If none type in "none."
Name and ages of anyone else residing in the home: (if none, type in "none." If box is left empty, an error will occur.)
How many hours during the day will your pet be left alone?
What is your work schedule? Is anyone in the household retired?
Will your pet be crated?
If pet is not crated, where will it be kept when you are not home?
Have you or are you currently using a Doggy Door?
Yes have used them in the past.
Yes, we use them currently.
No, never used them.
Where will the dog sleep at night?
Name & Phone # of the Veterinarian you use now or one you have had in the past.
How many dogs you you currently own now?
Describe them: Breed, Sex, Weight, Age, how long have you had them and are they spayed/neutered?
What brand of dog food do you currently feed your dog? (If you do not have a dog at this time, what brand of dog food did you used to feed your dog?)
How many cats do you own?
Are your cats spayed/neutered?
Do not have cats
Do you own any other type of animals? If no, type in "none."
If you own other cats and dogs, are they current with all of their vaccinations?
What happened to the pets you have had in the past. Click all that apply:
Died of old age
Died of illness
Died in an accident
Got hit by a car
Had to give up
Never owned a pet.
If you ever had to give a pet away OR if your pet every died in an accident; please explain the circumstances:
Do you have a fenced in backyard?
Will install a fence
Dog is walked on leash only.
Do you have a Swimming Pool or a Hot Tub?
How long have you been at your current address?
Do you live in a:
Do you own or lease?
If you have a Landlord do you have his permission to have a dog?
Do not have a landlord
Any restrictions on pets in your community?
Are you planning on moving in the near future?
Do you understand that often times the complete history of a rescue dog may not be known?
I only want to adopt a dog who's history is known.
Social/Behavioral problems you could not handle or would not want to correct: (Click all that apply)
Aggression towards Cats
Aggression towards Dogs
I can handle it all!
Who will be responsible for the medical care and training of this animal?
Medical condition(s) you are not able to handle.
Are you willing to keep the dog for life?
Yes, unless I can no longer afford to.
Yes, unless it gets sick.
Yes, unless I move to a place that doesn't allow pets.
Under what circumstances would you give up a dog?
Who would take your pet if something happened to you? Please list their name, address and phone number here:
Are you willing to work with housebreaking issues?
I want a dog that is totally housebroken
What brand of Heartworm Preventative do you currently use? If none, type in "none."
What brand of Flea Control do you currently use? If none, type in "none."
There are times when unexpected and often very expensive medical conditions occur. What will you do if this happens to your pet?
When are you available to adopt one of our dogs?
After my planned vacation.
After my planned business trip.
After the holidays.
After my surgery.
If you are not prepared to adopt a dog from us immediately, please let us know the date you will be available.
Do you have a Facebook page? If so what name is it under?
Type in any comments you wish to about you and your family that might help us match you with a pet.
I, Undersigned, agree to the following statements:
* The information I provide will be verified before I am approved for adoption. * Falsification or omission of any of the above information will result in automatic refusal of adoption or return of the pet to "A Better Life Pet Rescue." (please type in signature)
Date this application was sent in: