IL

IL-MO Rescue, NFP Adoption Application

Part I: Personal Information

Name/Date:

Address:

City:

Evening Phone:

E-mail address:

Number of adults in the household:

Are you expecting a child or planning a family in the near future?

Type of Dwelling: [ ] House [ ] Apartment [ ] Trailer [ ] Condo/Townhouse [ ] Duplex/Triple [ ] Other - explain:

Do you own or rent? [ ] own [ ] rent

Part II: Type of Rescue

If interested in a particular dog/cat, please specify who:

Would you accept a "special needs" dog (vision-impaired, not housetrainable, etc.)? Be specific.

Are you agreeable to returning the dog, should unforeseen circumstance arise wherein you would no longer be able to keep the dog?

Would you be willing to allow us to visit your home?

Have you applied with another Rescue Group? If so, which organization?

If out of state, will you make provisions to get the dog?

Part III: Environmental Information

How large is your yard (approx.)?

Is it securely fenced?

If yes, what kind and how tall?

If no, will you fence it if you get a dog?

Do you have a pool?

If yes, is it securely fenced?

If your yard is not fenced, how do you plan to insure that the dog receives safe and adequate exercise?

Where will the dog sleep? Be specific (in the kitchen, in my bed, etc.)

Do you plan to keep the dog primarily indoors or out? Please elaborate

Do you plan to use a crate?

Why or why not?

Part IV: Pet History

List all pets you currently own:
Dogs:
Breed/Name	Sex	Age	Spayed or Neutered?	Stay Indoors or Outdoors

Cats:
Age	Declawed?	Spayed or Neutered?	Stay Indoors or Outdoors

Other:
Breed	Age	Spayed or Neutered?	Stay Indoors or Outdoors


Have your current pets ever lived with a dog?

List any pets you have previously owned:
Species/Breed	How Long Owned	Kept Indoors or Outdoors?	Spayed Or Neutered	Where is pet now? If deceased, cause of death?




Have you ever had to give up a pet? If yes, please tell us why:

If you currently own a dog, or have ever owned one in the past, please complete this portion. If not, please skip this box.

Where did you get this dog (s)?

What activities do you participate in with your dog:

Have you attended obedience classes with your dog?

What type of Heartworm Preventative do you give your dog?

What type of flea control do you use on your dog?

What do you feed your dog (brand/type)?

Is your dog spayed or neutered?

Why or why not?

When nobody is home, where does your dog stay?

[ ] In the yard [ ] In a crate [ ] In the garage [ ] In the house confined to an area

[ ] In the house not confined to an area [ ] In the house with a doggie door [ ] In an outdoor dog run/pen

Do you consider your current dog(s) aggressive or submissive to other people? Animals?

Part V: Behavior
What type of behavior(s) do you expect from this dog?
What amount of time and effort, per week, do you want to devote to training your dog?	[ ] 3-5 hours [ ] 7-10 hours [ ] 5-7 hours [ ] 10+ hours
Are you likely to enroll your dog in obedience class? Which family members would be expected to assist in home training?
What is your definition of disciplining your dog?
What are your training objectives?
What makes you a good pet owner?

Part VII: References

Please list three references that can attest to your suitability as a pet owner, and more specifically, the owner of a rescued dog. If you have owned any pets in the last five years, please include your veterinarian as a reference.

Reference #1 (current vet if applicable):

Name Address City, State, Zip Phone

Reference #2:

Name Address City, State, Zip Phone

Reference #3:

Name Address City, State, Zip Phone

I, the undersigned, attest that, to the best of my knowledge, the above information is accurate and complete at the time of signing. I understand that falsely provided information can mean that my application will be terminated. I understand that by typing my name, I am signing this document (please sign and date).

Signature/Date:

Thank you for your cooperation. A comprehensive questionnaire helps us in placing the right dog with the right family. An improper placement or one in which all the details aren’t known, can end tragically, usually for the dog.

Thank you again.