First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County

Email*

Home Phone*

Cell Phone*

Text/Pager Email

Which animal are you interested in
Choose an animal: Arbor Arwen Ash Axel Blossom Bram Stoker Brownie Callie Church CoCo Della Floppy Francesca Galadriel Gandolf Harrison Ford Ivey Lee Lestat Penelope Sage Seeka Tina

Do you own or rent your home? If rent, provide landlord name and number.*

Does your home have a fenced in yard or fenced area for the pet? *
Choose one: Yes No

If you rent, please enter your landlord's name and phone number*

If you rent, have you received the approval of your landlord to have an animal*
Choose one: Yes No

Does anyone in the home have allergies? *

How many Children live in the home? List ages of each child.*

How many people reside in your household*

Who in the household will care for the pet*

Does everyone in the home want to adopt this dog? *

Where will the animal be kept when you are home*

Will the animal be kept inside or outside*
Choose one: Inside Only Outside Only Inside and Outside

Where will the animal sleep*

Where will the animal be kept when you are not home*

How much time will the animal spend alone during the day*

What traits are you looking for in a pet

List all current pets you own. Name, Age, breed, Spayed/Neutered, Up to Date on Vaccines?*

Veterinarian's Name and Phone Number*

Do we have permission to contact your veterinarian? (Please note, if you put "no" to contacting your vet, then we can not process your application.) *
Choose one: Yes No

Expenses for special needs pets can be costly and may require specialist veterinarians. Are you willing to take this pet to a specialist? *
Choose one: Yes No

Are your pets on monthly prevention? (flea/tick/heartworm) If no, why not?*

List pets that you have owned in the past, and their history.*

List 2 personal references. Name, Number, and Email.*

Have you ever given up a pet? If yes, please explain*

Have you applied with any other rescue*
Choose one: Yes No

How did you hear about us*

I certify that the information entered on this applicant is true. Enter your name and date*