Dog Adoption Application

Which dog are you interested in adopting?
If no specific name, please describe the type of pet you are looking for.
Individual or Couple *
Primary First Name *
Primary Last Name *
Primary Cell Phone (000-000-0000) * Please use the following format 248-555-1212
Primary Email * Please make sure to enter this correctly, as this is the main way we will contact you
Home Phone (000-000-0000) Please use the following format 248-555-1212
Secondary First Name *
Secondary Last Name *
Secondary Cell Phone *
Secondary Email
Street Address *
City *
State *
Zip Code *
Primary Person's Age *
Primary Person's Birth Date *
Employment Status *
If you are employed, please list employer name. If you chose "other" above, please explain:
Please list names AND ages of all adults who live or frequently stay in your home. *
Please list names AND ages of all children who live or regularly stay in the home. *
Is your residence: House/ apartment/ condo/ townhouse/ mobile home/ other? *
How long have you lived at this address? *
Do you own or rent your home? *
If you rent or do not own your home, does your landlord/ lease/ homeowner allow dogs? Are there breed or size limits? *
If you do not own your home, please list homeowner/ landlord name and phone number. *
Would you consider your home:	Quiet Moderate Active Very Active
Please tell us why you would like to adopt this pet.
Is this dog for you or for someone else? If not for you, who is it for? *
Is everyone in your household aware that you are planning to adopt a dog? *
Have you ever sold a pet, given one away or turned one into a shelter? If yes, please explain the circumstances. *
How much experience do you have with living with, raising and training dogs? *
Does anyone in your household have allergies to dogs? If so, who and how will you keep this from becoming a problem? *
Will this pet be kept inside your home all of the time, part of the time or none of the time? *
On average, how many hours per day will your pet be left alone? *
When left alone, will this pet be left loose/ crated/ outside/ garage/ other? *
Where will this pet be kept during the day? *
Where will the dog sleep/ be kept at night? *
Is your yard completely and securely fenced? If so, what kind of fence and how tall? *
If you do not have a fenced yard, how will you prevent the dog from leaving your yard?
Are you willing and able to exercise this dog on a regular basis? If yes, what is the method of exercise? If no, how will you keep them busy/ occupied? *
Will this dog ever be chained/ tied/ cabled/ kenneled outside? If so, when and for how long each day? *
How would you handle destructive behavior or housetraining issues? *
What will you do if this dog bites, scratches or scares a family member or friend? *
Will you keep this dog up-to-date on vaccinations and heartworm/ flea preventative? If no, please explain: *
Have you ever been convicted of abuse or neglect of a child or animal? If yes, please explain: *
If you are unable to care for this pet for any reason (illness/ death/ other) do you have someone who could either care for it or get it back to our rescue? If so, who? *
What would you do with this dog if you had to move? *
What will you do with the dog if you go on vacation? *
For what reason(s) would you consider returning/giving up the animal? *
Are you willing to take responsibility for this pet for the next 10-20 years? If no, please explain. *
How did you find out about us?
Is there anything else you would like to mention that was not asked on the application?
Current Pet Info
Are there currently any dogs living on your property? *
Please tell us name, age, sex and breed/ mix or size of every dog: Example: Spot, 1 year old male, large lab mix *
Are all dogs on the property Spayed or Neutered? If not, please explain. *
Are all dogs on the property up to date on recommended vaccinations and heartworm preventative? If not, please explain. *
Where do the current dogs live (inside/ outside/ barn/ kennel/ etc.) *
Are there cats living on your property? *
Please tell us the name, age and sex of every cat: Example: Fluffy, 1 year old male *
Are all cats living on the property Spayed or Neutered? If not, please explain. *
Are all cats living on the property current on recommended vaccinations? If not, please explain. *
Where do the current cats live? (inside/ outside/ both/ in the garage or barn/ etc.) *
Please list ALL other pets (besides dogs/cats) living at this address by species (rabbit/ horse/ chickens/ hamster/ etc.) and where they live.
Are all other pets at this address good with dogs? If not, please specify which one(s) and what you will do if they don't get along.
Please name ALL other pets you’ve owned in the last 5 years, and why you no longer have them. If they passed away, please state cause of death *
References
Current/ Past Veterinarian or Clinic Name * If you have never owned a pet please tell us where you would go.
Veterinarian's City and State * Again if you have never owned a pet, please list where you would go
Veterinarian's Phone Number *
Please list the name and contact information (telephone or email) of two personal references - NOT related to you or living in the same household. *
Please carefully read the following policies. Signify your agreement to adhere to them by signing below.
I have read the foregoing and certify that the answers I have given are complete, true and not misleading in any way. I understand that omission of information and/or failure to answer all questions truthfully can result in this application being denied. I understand and accept that if an omission or untruth is discovered after an adoption takes place, Midwest Pet Refuge has the right to annul the adoption agreement and repossess the adopted pet. I understand that Midwest Pet Refuge reserves the right to refuse the adoption of any animal to anyone for any reason, and that all Adoption Fees and Donations are non-refundable. I give Midwest Pet Refuge permission to investigate all information provided, as well as contact veterinarians, landlords, references and related officials. I understand that Midwest Pet Refuge makes every effort to place healthy animals, but that they cannot guarantee the health, breed, age or temperament of any animal, and by signing I agree that Midwest Pet Refuge shall not be held responsible for any injuries, property damage, medical, veterinary or other expenses which may be incurred after adoption. I understand that I am responsible for and financially prepared to provide proper shelter, sufficient high quality food, water and all necessary medical treatment for this pet, including the following: vet recommended vaccinations, flea control, vet care for unexpected injury/ illness, etc. in order to keep this animal healthy and comfortable as an indoor pet. If this is not done, I understand that the Midwest Pet Refuge has the right to repossess the animal. I understand that if I ever cannot properly care for/ have to give up this animal, it MUST be returned to Midwest Pet Refuge. If this is not done, I understand that Midwest Pet Refuge has the right to reclaim the animal. I agree to never harm or abuse the adopted pet in any manner.
Please Type Signature to confirm you agree with the poilicies stated above. Thank you! *

Check all entries for accuracy, then press the "Submit" button ONLY ONCE. If you do not receive a confirmation email after you hit Submit, please re-submit your application.

Dog Adoption Application

Current Pet Info

References

Please carefully read the following policies. Signify your agreement to adhere to them by signing below.