Name of Dog you wish to Adopt? *
Your Name: *
Your Spouse/Partner/Roommate's Name: *
Your Complete Address: *
Do You:
Own Rent Other
Name & Number of Landlord:
Do you live in:
House Apartment Other (please explain):
Other Explain:
Length of Time at Address: *
Explain if Less than 2 years:
Phone Numbers: ( Home, Cell & Work ) *
Email address: *
Do you have a Fenced in Yard?:
Yes No
If Yes, Please explain the Type and Height:
Your Age: *
Age of Children:
Occupation: *
How long in Current Occupation?:
How Many Hours a week do you Work?: *
Reason for wanting to Adopt :Companionship Hunting Dog Guard Dog for Children Companionship for another dog/animal Other (Please Explain)
Please explain Other reason:
Where will the Dog be when you are not home? e.g., work: *
Where will the dog be when you are on vacation?:
Will Stay with Friend or Relative Boarding Kennel Dog will go with us Other ( Please Explain)
Explain other vacation stay plans:
How many hours do you leave your pets alone each day?: *
How will your new dog spend his or her days?: *
If you currently have pets, please list breed, age, sex and temperament:
Do you have a cat or cats? If so, do they get along with dogs?:
Yes No (please explain)
Please Explain why they do not get along with Cats:
Are your pets spayed/neutered?:
Yes No (please explain)
Please explain why your pets are not spayed/neutered:
Are your pets on heartworm prevention & flea & tick control?
Yes No (please explain)
Please explain why they are not on these preventatives and controls:
Are you financially able to afford heartworm prevention, flea & tick control, and veterinary care?
Yes No
Will your new dog have yearly well check visits & vaccinations at your veterinary office?
Yes No
Name and Phone Number of your vet or previous vet: *
Have you ever given a pet away, if so, for what reason?: *
Under what circumstances would you consider giving up your pets?
Moving Baby Not getting along with other pets Behavioral problems Allergies Children lost interest Too time consuming Separation/Divorce Medical issues Other (please explain)
Please explain what those other reason are:
Would you welcome a home visit by one of our volunteers to check on how you and your new pet are doing?
Yes No
Do you agree to return the dog to SQ Rescue if for any reason you can no longer keep him/her?
Yes No
Are you willing to make a 10 - 20 year commitment for this dog?
Yes No
Please list two references, excluding relatives, to include name, relationship & phone number: *
Security Code: *
Before Submitting, I hereby state that all the information provided in this application is true and correct:
