Online Adoption Form

Applicant 1: First Name

Last Name

Age

Applicant 2: First Name

Last Name

Age

Applicant 1: Occupation

Applicant 2: Occupation

Email Applicant 1

Email Applicant 2

Address

City

State

Zip

App 1: Hm Phone

App 2: Hm Phone

App 1: Cell Phone

App 2: Cell Phone

App 1: Work Phone

App 2: Work Phone

Pet Selection

Which dog are you interested in (name)?

Do you have a second choice (name)?

Gender preference?

Male

Female

Would you take a special needs dog?

Yes

No

Why do you want a Yorkie?

Home Info

Do you live in a house or apartment?

House

Apartment

Do you own or rent?

Own

Rent

If you rent, do you have your landlord's permission to own a dog?

Yes

No

N/A

What is your landlord's name and phone number?

Fence Info

Do you have a fence?

Yes

No

If Yes, is it attached to your home?

Yes

No

Is it secure?

Yes

No

What type of fence is it?

What is the height of the fence?

Family Life

Do you have children at home?

Yes

No

N/A

If Yes, what ages?

Who will be responsible for taking care of this dog?

Will there be someone home during the day?

Yes

No

Where will the dog be kept when no one is at home?

How many hours would your dog be alone on an average day?

Where will the dog be kept at night?

Where will the dog exercise?

Under what circumstance will you give up your dog?

Other Pet Experiences

Do you have other pets?

Yes

No

N/A

# of cats

# of dogs

List all types of pets in the home

List the breed of all dogs in the home

Are they all current on all vaccines and heartworm preventions?

Yes

No

N/A

Are all your cats or dogs spayed or neutered?

Yes

No

N/A

Please provide us with your veterinarian’s name and phone number.

References

Name

Phone #

Name

Phone #

Name

Phone #

I certify that the information provided on this form is true & correct. I am also financially
and physically able to care for this animal. I understand that proper food and veterinarian care may be costly, and I am able to meet these requirements. Home checks are made
on a random basis following or prior to adoption. If upon inspection we find that information contained in this application to be false, we retain the right to turn down or remove the animal from your premises without a refund of moneys paid.

Printed Name

Date

Your signature will be required below when you pick up your dog.

Name

Date

Indicates Response Required