Form

This questionnaire has been designed to aid us in determining if potential adoption homes are prepared to assume the type of responsible pet ownership we endeavor to assure for our rescued animals. Our goal is to be thorough, not invasive. Please answer all questions honestly and feel free to add your own comments. Please keep in mind that providing false information will result in the nullification of this application.

IF A QUESTION DOES NOT APPLY, PLEASE WRITE N/A. ALL FIELDS MUST BE FILLED.

Pet Interested In

Today's Date:

/ Month / Day Year

ABOUT YOU
(Person applying must be 21 years of age and the primary individual responsible for this animal)

Full Name*

First Name Last Name

Daytime Phone*

- Area Code Phone Number

Evening Phone

- Area Code Phone Number

E-mail*

Best time to call:

Address

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

Applicant's Age*

Marital Status

Married Single

# of adults in home

List all other people in home

Other person in home

Age/Relationship

Other person in home

Age/Relationship

Other person in home

Age/Relationship

Occupation

Occupation of Spouse

If this relationship were to change, with whom would the dog remain?

Who will be primarily responsible for the care of the dog?

Do you have children?

Yes No

If yes, do they live with you?

Yes No N/A

Have they been around a dog?

Yes No N/A

Children ages (if any)

If no children now, do you plan to have a family in the future?

If yes, when?

What are your reasons for adopting a dog?

Would you consider a dog with special needs (check all that apply)?

What qualities are you looking for in a dog?

What breed are you looking for?

Are you familiar with the temperament of this breed? If yes, how so?

Would you prefer male or female?

Would you prefer specific colors or markings?

Preferred age range?

Do you have any concerns about adopting?

I consent to a home check in the event my application is accepted.

Yes No

Type of Dwelling:

Rent or Own

Rent Own

Are pets allowed?

Yes No

Years at residence

Do you have a landlord? HOA?

Landlord HOA N/A

If yes, may we contact them?

Yes No

Landlord/HOA Owner Name and Phone #

Where will dog(s) stay during the day?

If the dog(s) stay inside, does he/she have access to the outside?

Yes No

If the dog(s) stay outside, how many hours a day will he/she be left outside?

What outside space is available for the dog(s)?

What type of fenced yard do you have (also list height of fence)?

Is there a grassy area? Is it fenced?

Grass w/fence Grass - no fence No grass

Do you have a pool?

Yes No

What other access areas do you have for the dog(s)?

Will the dog(s) be tied up?

Yes No

Are there areas where the dog(s) are not allowed (please list)?

Are you planning to move within the next 6 months?

If you ever had to move, would your dog come with you?

Holly's Garden Rescue Adoption Application