ADOPTION FORM  

All Information Submitted Is Kept Confidential

Applications are processed and considered in the order they are received. Please complete this form in it's entirety then click on submit when finished. Thank You

Incomplete applications will NOT be considered

References are required and MUST be given

SECTION A: YOUR DETAILS  

Full legal name, first and last (no nicknames):

Street address:

City, State, Zip code:

Home phone number including area code :

Work phone number including area code :

Cell phone number including area code :

Email address (required) :

Breed of dog you are interested in:

Age range you are interested in:

Dog you are interested in more information on:

Will this be your first pet?

Yes
No

If this is your first pet, what vet have you chosen:

Street address of chosen vet:

City, State, Zip code of chosen vet:

Phone number including area code of chosen vet:

SECTION C: YOUR HOME  

Your living situation:

Home
Farm/Ranch
Condo
Apartment
Mobile Home

Is your yard fenced:

Yes
No

Own or rent:

Own
Rent

If rented, your landlord's name:

Your landlord's street address:

Your landlord's City, State, Zip code:

Your landlord's phone number including area code:

SECTION D: OTHER RESIDENTS  

Number of adults living in the home:

One
Two
Three
Four or more

Number of children living in or regularly in the home:

None
One
Two
Three
Four or More

Age of children (starting with youngest):

Number of other pets in the home:

None
One
Two
Three
Four or more

Breed, age and gender of other pets living in the home:

SECTION E: PET MEDICAL INFORMATION  

Your current vet's name:

Your current vet's street address:

Your current vet's City, State, Zip code:

Your current vet's phone number including area code:

Are your current pets up to date on all shots:

Yes
No

Are your current pets spayed or neutered:

Yes
No

Are your current pets on heartworm prevention:

Yes
No

Type of heartworm prevention:

SECTION F: HOUSING

Where are your current pets kept during the day:

Whereare your current pets kept during the night:

How many hours per day are your current pets left alone:

How many hours a day do you anticipate a new pet will be left alone:

SECTION G: REFEREES  

Provide a minimum of three (3) references including name, address and phone number - two (2) of the referees being non family members:

Referee 1

Referee 2

Referee 3

Referee 4

SECTION H: OTHER

We often get "special needs" pets, either with physical restrictions or health problems that need homes. Are you interested in a special needs pet?

Yes
No

Comments ?

Before submitting, CHECK and make sure ALL fields are filled in using n/a if a question does not apply to you. Incomplete Adoption Applications can NOT be processed and will be automatically deleted

By clicking the Submit button I declare that the above information is accurate and true and that I have read, understand and agree with the terms of Heavenly Acres Pet Rescue's ADOPTION POLICY. I hereby declare that I am financially, physically and emotionally capable of properly caring for an animal and am committed to properly caring for any animal adopted from Heavenly Acres Pet Rescue. If any information provided by me as part of this application is found to be untrue or misleading, I understand and accept that the animal adopted by me from Heavenly Acres Pet Rescue can and will be removed from my possession without a refund if neglect or abuse is evident

Thank You and God Bless

Date of application: