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Applicant's Name *
Driver's License *
Street Address *
City/State/Zip *
How did you hear about us? *
Why do you want to adopt a dog *
Where will your dog spend most of his/her time? *
On a scale of 1 (quiet) to 5 (high) what energy level are you looking for? *
Hair length of the dog you want to adopt (long, med, short)? *
Upon adulthood, how large do you want your dog to be (small, med, large) *
What age dog do you want (young, adult, mature)? *
If adopting a puppy, do you realize that you may have to get up at night or come home during the day for potty-breaks? * Yes No
Do you realize there is an adjustment period for house-training a new dog? * Yes No
What house-training method do you use? *
Please list all pets living with you: *
What happened to pets that are no longer with you? *
Do you know what heartworm is? * Yes No
If you rent - please provide Landlord contact info (or type *
Number of adults in your household? *
Please list the ages of all children living in the home: *
Do you have a fenced in yard? * Yes No
Please list your Vet's contact information: *
Please list the contact information of three (3) referrences: *
DISCLAIMER You must be at least 18 years of age to adopt a dog. You may be refused the right of adoption if the consensus of the screeners is that adoption to your home would not be in the animal’s best interest. We reserve the right to check on any adopted animal in the future, and as a final measure, will reclaim the animal if improperly treated or housed, or if false statements were made on the adoption application. We insist that you have your animal checked by a veterinarian within one week of adoption, if a very recent examination has not occurred. The animal must immediately be placed on heartworm preventative and kept on it year round. We acknowledge that an animal’s personality and behavior may be altered by placement in any new environment. Knowing this you (the “adopter (s)”) agree to not to hold liable Animal House Rescue or any of it’s representatives for any damage caused by said animal after the adoption. If an adoptive family encounters difficulties with a new dog, we will aid in correcting the problem if possible. The adoption fee refund only applies for sick animals returned within 10 days of adoption. By checking yes you state that you understand and agree to all the terms and conditions of the Disclaimer. * Yes No
By marking "Yes" you are verifying that all of the information you've provided is true. And, you agree that clicking "Submit" is acceptable as your signature. * Yes No


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