Please complete every question. If it does not apply write N/A. Phone Name of Dog Applied for: Where did you first see this Adoptable: Applicant Name: Date of Birth: Email Address: Cell Phone: Legal Address (Street Address) City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Rent/Own: Select One Rent Own Type of Home: How long at this address? Landlord Name Street Address State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Landlord Phone Number: Is your landlord aware of your interest in adopting a pet? Yes No Any breed stipulations, deposit requirements (be specific)? What happens to the pet if you move? Previous Address Rent or Own Rent Own Select One How Long At? Primary Social Media Page and Source: List all residents of this address including current pet: Name Resident or Pet name 1 Resident or Pet name 2 Resident or Pet name 3 Resident or Pet name 4 Resident or Pet name 5 Resident or Pet name 6 Resident or Pet name 7 Resident or Pet name 8 Age Resident or Pet age 1 Resident or Pet age 2 Resident or Pet age 3 Resident or Pet age 4 Resident or Pet age 5 Resident or Pet age 6 Resident or Pet age 7 Resident or Pet age 8 Relationship or Type of Pet Resident or Pet relationship 1 Resident or Pet relationship 2 Resident or Pet relationship 3 Resident or Pet relationship 4 Resident or Pet relationship 5 Resident or Pet relationship 6 Resident or Pet relationship 7 Resident or Pet relationship 8 Male or Female Resident or Pet gender 1 Female Male Select Gender Resident or Pet gender 2 Female Male Select Gender Resident or Pet gender 3 Female Male Select Gender Resident or Pet gender 4 Female Male Select Gender Resident or Pet gender 5 Female Male Select Gender Resident or Pet gender 6 Female Male Select Gender Resident or Pet gender 7 Female Male Select Gender Resident or Pet gender 8 Female Male Select Gender Are Pets vaccinated and spay or neutered? Yes No Do pets have a microchip? Yes No Current Veterinarian’s Name Previous Veterinarian’s Name Current Veterinarian’s Phone: Previous Veterinarian’s Phone: Personal Reference #1: Name Personal Reference #2: Name Personal Reference #3: Name Personal Reference #1 Phone: Personal Reference #2 Phone: Personal Reference #3 Phone: Employer Employer Phone: Length of Time with Current Employer: Any pets in the past? How will pet be exercised? Average time away from home daily? Where is pet now? Where will pet be kept when away from home? Where will pet sleep at night? If they did not cross the rainbow bridge due to age or sickness, why are you no longer responsible for them? If due to sickness please explain? Does the home where pet resides have a fenced in yard? Yes No Does anyone who lives in home have allergies? Yes No Does anyone in the home require medical equipment that may startle a new pet? Yes No Have you or anyone in your household ever been convicted of animal cruelty, neglect, or abandonment? Do you believe a dog should receive lifetime training? Yes No How do you plan to train your pet? Please explain why you would like to adopt the pet you are applying for. If for any reason we do not determine this pet is a good fit, are you interested in us suggesting another that may be a better suited to your lifestyle? Yes No I, certify that all information provided in this application is true. I give K-9 Rescue Partners of Hernando Inc permission to verify information as needed. I will contact my veterinarian and references to give them permission to speak with a representative of K-9 Rescue Partners of Hernando Inc. I understand that a home check is required prior to completing the adoption process. Any false statement will terminate potential adoption. * Date *
