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Name of Dog:__________________ Breed:______________ Sex:____
Age:_____ Spayed/Neutered:_______ Health:_____________________ |
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Owners Name(s):______________________________________________
Address where Dog will reside:___________________________________ ____________________________________________________________ Telephone: Home ( ) ______________ Mobile ( ) _____________ Driver's License No.:____________________________ State:_____ Email:__________________________ |
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Occupation:______________________ Work Phone( )_________________
Employer:________________________ How long employed there:________ Employer Address:______________________________________________ _____________________________________________________________ |
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Do you own or rent:_______ How long have you lived there:________
If you rent, provide landlord's name, address and phone number: _______________________________________________________ _______________________________________________________ Are you planning on moving in the near future:_____ If you move in the future, what will you do with your pet(s)? _______________________________________________________ Who else resides with you and what is their relationship to you: _______________________________________________________ Do you currently have pets:______ If yes, list all species and breeds: Name, address and phone number of current veterinarian: Have you had pets that you no longer have:______ If yes, please explain why you no longer have the pet(s): Why would you like to adopt? Please list if there is a specific pet you wish to adopt: If for any reason you are unable to keep this dog, do you agree to return this pet to Rescue Rehab Home? Would you be willing to allow us to visit your home for an interview and to check for a safe and secure environment for this pet? I certify that the above information is true and correct and agree to the Rescue Rehab Home Terms of Adoption, a copy of which I have recieved and read. I further acknowledge that I am responsible for the care, well being, and actions of the Dog effecive on the date hereof, and that as of such date Rescue Rehab Home shall have no liability for any action of the Dog, or as a result of the adoption of the Dog by Applicant. SIGNED this___ day of_________ 2005 __________________________________ Applicant Signature __________________________________ Printed Name RESCUE REHAB HOME INC |