Name of Applicant:

Age of Applicant:

Which dog(s) are you interested in?

Occupation:

Spouse/Significant other's name:

Spouse's Occupation

Names and Ages of Children (if Any)

Any other occupants in home:

Home Address:

City/State/Zip

How long have you lived at this address?

Home phone: Work phone:

Cell Phone

Best time to call:

E-mail:

If renting do you have permission from landlord to have a dog?
Yes
No

Landlord's name:

Phone:

What are your primary reasons for wanting a dog? (check all that apply)

Companion
For your children
Gift
For other pet
Watchdog
OTHER

If you have children, please describe their previous experience with dogs:

Does anyone in your household have allergies?

Yes
No

Describe:

Other pets? (Sex, Breed, & Age of each)

Dogs:

Cats:

Other:

Are your pets spayed/neutered?

Yes
No

Have you ever allowed an animal to breed?

Yes
No

Do you have a yard?

Yes
No

How big is the yard?

Aproximate square footage of house?

How many hours per day will the dog be left alone?

Where will it be left alone?

How many hours a day will you spend with your dog?

Where will the dog sleep at night?

Dog House
Garage
Laundry Room
Kitchen
Master Bedroom
Bathroom
Child's Room
Other (explain)

What outside areas are available to the dog?

Fenced Yard
Enclosed Patio
Garage
Balcony
Dog House
Unfenced Common Area
Other

Type of fencing?

Chain Link
Wood
Block Wall
Iron Rod
None
Other

Do you have a doggie door?

Yes
No

Height of fence:

Highest Point:

Lowest Point:

Are there gates?

How many?

How high?

Is there any type of lock on the gate(s)?

Padlock
Key
Latch
Other

Have you recently inspected your fence and is it secure, without holes, gaps, or low points?

Yes
No

If NO, and your application is accepted, do you agree to thoroughly inspect your
fence and make any necessary repairs before the home visit?

Yes
No

Do you have a pool?

Yes
No

If yes, is there a secure fence around it?

Yes
No

Who has access to your yard? (check all that apply)

Gardener
Poolman
Housekeeper
Utility
Neighbor

Preferred level of exercise with dog? (check all that apply)

Couch Potato
Short Walks
Vigorous Walk
Hike/Jog

When you go on vacation who will care for the dog?

What brand of food will you feed the dog?

Wet:
Dry:

Do you have a regular vet?

Yes
No

Vet Name/Phone #:

Would your dog wear a permanent RESCUE I.D. tag and collar?

Yes
No

How would you rate your level of dog owning experience?

1st Time Owner
Beginner
Intermediate
Advanced
Other

How would you discipline your dog if he or she misbehaved?

When on leash you normally use:

Collar Only
Choke Chain
Harness
Other

Pets are an investment of your time and money. Can you afford to provide timely medical
care, grooming, proper diet, shelter and exercise for your new pet?

Yes
No

Are you able to make a long-term commitment to care for your pet for its entire life span,
which could be as much as 10-15 years?

Yes
No

What would happen to your pets if you moved?

If something were to happen to you where you could no longer care for this dog do you have
anyone (friends, family) who would be able to take him/her into their home?

Have you ever given a pet away? If so, please explain.

Will you agree to consult and pay for a trainer or behaviorist if any problems develop?

Yes
No

Please list pets you have owned since you have been an adult: (include the type of animal, the length of ownership, and what happened)

How did you find out about Take Me Home?

Have you ever adopted from a rescue before?

List a personal reference that does not live with you: (Name and number)

Any other comments you feel are pertinent to your dog adoption:

Please read and initial each statement below.

I understand that a home visit does not guarantee placement [initial]

I agree to provide my own collar, leash, choke chain or harness, and personal ID (can be
purchased at our adoption events) at the time of completing the adoption contract
[initial]

I certify that the information contained in this application is true and correct and I
understand that prior to the placement of a dog in my home, the information will
be verified. I also agree to a personal interview and home inspection to
determine the suitability of my facilities to care for a rescued large breed dog.

Please enter your full name and the name as your signature:

SIGNATURE

Printed name:

DATE:

Thank you for considering a dog from Take Me Home!