Jeff Tarpley Rescue Adoption Application

Today's Date * +

First Name of Applicant *

Last Name of Applicant *

Age of Applicant *

First Name of Co-Applicant

Last Name of Co-Applicant

Age of Co-Applicant

Street Address *

City *

State *

Zip Code *

Phone Number *

Type of Phone *

Other Phone

Type of Phone

Email Address *

Please list occupation and employment information for all applicants.
Include work address and phone numbers. *

How did you hear about Jeff Tarpley Rescue? *

Which animal are you interested in adoptiong?
Please include name/breed/sex/etc *

How many other pets do you currently own or have living in your home? *

Name

Breed

Age

Spayed/Neutered?

Sex

Name

Breed

Age

Spayed/Neutered?

Sex

Name

Breed

Age

Spayed/Neutered?

Sex

Are your dogs currently on Heartworm preventative?

What other pets have you had in the last 5 years (not listed above) and where are they now?

Have you ever adopted a pet from a shelter or rescue before? *

If yes, what type of pet did you adopt?
Please provide contact information (name address phone) for the rescue or shelter.

How many children live in your home? What are their ages?
Include any children/grandchildren who visit your home on a regular basis. *

How many adults live in your household? *

How often will the dog stay alone on a regular basis?
When alone, where will the dog stay?
During vacations/ family out of town, where will the dog stay? *

Descibe the area you live in. (city, suburban, rural)
Do you have a fenced yard? What type?
Do you plan to leave the dog outside, unattended?
If yes, please explain. *

Do you own or rent your home?
NOTE: Your name must be on mortgage or lease to adopt. *

I agree to all of the following:
I agree to notify Jeff Tarpley Rescue if I cannot keep my adopted pet.
I agree to allow a representive to visit my home during the adoption process and afterwards for a followup.
I agree to allow Jeff Tarpley Rescue to contact my landlord, veterinarian, and references.
I agree to provide monthly heartworm preventative and yearly vaccinations to my adopted pet. *

Please provide names and phone numbers for the following:
Landlord (if renting/leasing)
Veterinarian
2 References (non-family members) *