Please fill out the form below, if you would like, you may download a .pdf version here. Please Fax, E-mail, or Snail Mail it back to us. Thanks!

Age of Applicant:


Type of dwelling:



Other



If renting do you have permission from landlord to have a dog?

What are your primary reasons for wanting a dog? (check all that apply)






If you have children, please describe their previous experience with dogs:

Does anyone in your household have allergies?




Describe:

Other pets? (Sex, Breed, & Age of each)

Dogs:

Cats:

Other:

Are your pets spayed/neutered?



Have you ever allowed an animal to breed?


Do you have a yard?


Approximate square footage of house?

Where will the dog sleep at night?








Other

What outside areas are available to the dog?







Type of fencing?




Do you have a doggie door?


Height of fence:



Is there any type of lock on the gate(s)?




Have you recently inspected your fence and is it secure, without holes, gaps, or low points?


If NO, and your application is accepted, do you agree to thoroughly inspect your
fence and make any necessary repairs before the home visit?


Do you have a pool?


If yes, is there a secure fence around it?


Who has access to your yard? (check all that apply)





Preferred level of exercise with dog? (check all that apply)




What brand of food will you feed the dog?


Do you have a regular vet?


Would your dog wear a permanent RESCUE I.D. tag and collar?


How would you rate your level of dog owning experience?





How would you discipline your dog if he or she misbehaved?

When on leash you normally use:





Pets are an investment of your time and money. Can you afford to provide timely medical
care, grooming, proper diet, shelter and exercise for your new pet?


Are you able to make a long-term commitment to care for your pet for its entire life span,
which could be as much as 10-15 years?




What would happen to your pets if you moved?

If something were to happen to you where you could no longer care for this dog do you have
anyone (friends, family) who would be able to take him/her into their home?

Have you ever given a pet away? If so, please explain.

Will you agree to consult and pay for a trainer or behaviorist if any problems develop?




Please list pets you have owned since you have been an adult: (include the type of animal, the length of ownership, and what happened)

How did you find out about Take Me Home?

List a personal reference that does not live with you: (Name and number)

Any other comments you feel are pertinent to your dog adoption:

Please read and initial each statement below.

I understand that a home visit does not guarantee placement [initial]

I agree to provide my own collar, leash, choke chain or harness, and personal ID (can be
purchased at our adoption events) at the time of completing the adoption contract
[initial]

I certify that the information contained in this application is true and correct and I
understand that prior to the placement of a dog in my home, the information will
be verified. I also agree to a personal interview and home inspection to
determine the suitability of my facilities to care for a rescued large breed dog.

Please enter your full name and the name as your signature:

SIGNATURE

Printed name:

DATE:

Thank you for considering a dog from Take Me Home!