First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone*

What is the Name of the Animal you are applying for:
Choose an animal: BINGO BLUE COMING SOON! BUBBA - COMING SOON! Clover Darlene - Road Puppy Litter DARNELL Dusty Eden Felicity Gizmo Grace GUM DROP / Gunner - CANDY LITTER Houdini - Road Puppy Litter Kiwi Lady - Road Puppy Litter Layla Little Bit (AKA Lilly) Mia Monkey MOOSE Natasha -Coming Soon! Nebel Penelope ROWDY - COMING SOON! Ruby Sammi & Stevie Bonded! Silver Snoopy - Peanuts Litter Snoopy - Road Puppy Litter Snow - Coming Soon! Spot - Road Puppy Litter Wanda

What is your Date of Birth*

Name of your spouse / significant other living in the home?*

What is the Spouse/ Significant Other Date of Birth?*

Do you own or rent? *
Choose one: Rent Own

If you rent, what is your landlord name and phone number?

How long have you lived at this address?*

Do you intend to move soon?

If less than 2 years, what is the previous address ? If NA type NA

What is the name and address of your employer*

How long have you worked for this employer?*

What is the employer of your spouse / significant other?*

How long has your Spouse / Significant Other been at this employer ?*

List the Names and Date of Birth of other human members of the household*

Are all members of the household "on board" with and excited about adopting a pet?*

Does anyone in your household have allergies or asthma?*

If Yes, Explain:

Why do you want a dog?*

If not, Explain :

How long will your pet be left alone without human companionship each day?*

Are you willing to be patient and take time to allow your pet to adjust to you and your home?*

If No, Explain:

Are you Financially Able to provide annual and routine pet care (exams / vaccinations)?*

Are you able to make a LONG TERM commitment to care for a pet?*
Choose one: Yes No

Will the animal have access to all parts of the home?
Choose one: Yes No

If No, Explain

Do you have a yard?
Choose all that apply: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

What type of fence
Choose one: Privacy Chain Link Invisible

What is the height of the fence

Will you take your dog for daily walks?*
Choose one: Yes No

If No, Explain:

Do you intend to leave your dog outside for any extended periods of time?*
Choose one: Yes No

If Yes, Explain:

Do you want your dog to have puppies?

If Yes, Explain:

Are you willing to spend time and potentially money to make sure your dog is adequately trained?*
Choose one: Yes No

If No, Explain:

List your present and /or previous veterinarian(s) used. Include Phone Numbers and addresses. Please advise your veterinarian(s) that we will be calling - if they are aware, it will speed up the approval process. If none, write "NONE"*

List All Pets Currently living in your home: Include Pets Name, type (dog.cat, etc), breed (dog), sex, state if spayed/neutered, inside/outside, age. If none, write "NONE"*

List all pets you have owned in the past five years that no longer live with you. Include pets name, type, sex, age, spayed/neutered, kept inside/outside/both, and what became of that pet. If none, write "NONE":*

Have you ever given up a pet? If yes, please explain*

Please provides the Name, Phone Number, Email and relationship to you of at least 2 people. Do not use relatives. Excellent references are people who know both you and your pets. We will call the references as part of the approval process. *

How Did you Hear About Paws Up Pet Rescue?*
Choose one: Online Newspaper Ad Previous Adopter Word of Mouth Friend

By choosing "yes" below, I certify that the information I have given is true and that I recognize that any misrepresentations of facts may result in my losing my privilege to adopt a pet. I understand that Paws Up Pet Rescue has the right to deny my request to adopt an animal, and I understand that I authorize investigation of all statements in this application, including veterinary records. I certify my understanding of these things.