Adoption Application Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell PhoneWork PhoneHome Email Work Email EmployerOccupationWhat type of dog are you interested in? Female Male Are you looking for a Puppy (under 5 months) Adult Breed:Name of dog you are interested in:Personality type:Color:How many people currently reside in your household?Any children in the household? Yes No If yes, please list ages:For whom are you adopting the dog? Self Gift Who will be responsible for the dog's care?Where do you live? Apartment Condo Farm Mobile Home Townhouse House Do you own or rent your residence? Own Rent If you rent, what is the name of your landlord and phone number?Are companion animals allowed? Yes No Not sure Where will the dog be kept? Indoors only Outdoors only Both in/out When outdoors, will the dog be: (Select all that apply) In a fenced yard Walked on a leash On a tie out At the dog park Will anyone be home during the day? Yes No How many hours will the dog be left unattended?When no one is home, where will the dog be kept?If you move, what will you do with the dog?How far from the road/traffic is your home/farm located?Have you ever had a companion animal before? Yes No Is the volume of traffic: Light Moderate Heavy Describe those companion animals you still care for or that are living in your household (Please include Name, Age, & Breed).Are all of your animals spayed/neutered? Yes No Are your companion animals current on their vaccinations? Yes No Veterinarian's Name First Last Veterinarian's Phone NumberIf you have a dog, is he/she permitted to run loose? Yes No Are you financially able and willing to provide annual checkups, vaccinations, and ANY medical care necessary? Yes No What precautions would you take to properly introduce a new dog into your home if you have other animals (a dog, bird, rabbit, cat, etc.)?What will you do if your new dog does not get along with your present companion animals?Have you ever adopted an animal from a rescue/animal control agency? Yes No Have you ever had an application rejected for adoption of an animal from a rescue/animal control agency? Yes No If yes, please explain:Why do you want to adopt a dog?If a disciplinary or behavior problem arises, what steps will you take to work on it?Are you willing to sign legal pet adoption papers? Yes No Do you agree to permit a visit to your home/farm by appointment? Yes No Consent By signing this form, I/we acknowledge that all information on this form is true and correct. I/we understand that any misrepresentation of facts may result in refusing adoption privileges to me/us. If my/our request for adoption is approved and later discovers the above information is not true or correct, 4 Precious Paws Rescue reserves the right to remove the adopted dog from my home/farm without notice.Signature
