I am interested in adopting (name of pet)

Your Name / Age:

E-Mail Address:

Spouse/Partner/Age:

Address (mailing):

Address (physical):

How long have you lived at this address? less than 6 months . 1 year 2 years 3 years more than 3 years

City/State/Zip:

Telephone: (day)

Telephone: (evening)

Will you accept a collect call from us? yes no

Your employer: Phone:

Spouse employer: Phone:

Number of Children: 1 2 3 4 5 6 7 8 9 10 0 Ages: less than 1 year , 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 0 (control/click all that apply)

Is everyone in your household in agreement with adopting a Mutt Airedale Terrier Akita Alaskan Malamute Cocker Spaniel American Eskimo Dog American Staffordshire Terrier American Water Spniel Australian Cattle Dog Australian Shepherd Basenji Basset Hound Beagle Bearded Collie Belgian Malinois Belgian Sheepdog Belgian Tervuren Bernese Mountain Dog Bichon Frise Black/Tan Coonhound Bloodhound Border Collie Borzoi Boston Terrier Bouvier des Flandres Boxer Briard Brittany Brussels Griffon Bull Terrier Bulldog Bullmastiff Cavlier King Charles Spaniel Chesapeake Bay Retriever Chihuahua Chinese Crested Dog Chinese Shar-Pei Chow Chow Clumber Spaniel Cocker Spaniel Collie Corgi Dachshund Dalmatian Doberman English Mastiff English Setter Irish Setter Gordon Setter Finnish Spitz Flat-Coated Retriever Fox Terrier French Bulldog German Pointer German Shepherd Giant Schnauzer Golden Retriever Great Dane Great Pyrenees Greyhound Irish Wolfhound Italian Greyhound Jack Russell Terrier Japanese Chin Keeshound Kerry Blue Terrier Kuvasz Labrador Retriever Lhasa Apso Maltese Manchester Terrier Miniature Pinscher Miniature Schnauzer Newfoundland Old English Sheepdog Papillon Pekingese Pomeranian Poodle(Standard) Poodle(Miniature) Poodle(Toy) Pug Rhodesian Ridgeback Rottweiler Saint Bernard Samoyed Schipperke Shetland Sheepdog Shiba Inu Shih Tzu Siberian Husky Silky Terrier Standard Schnauzer Tibetan Spaniel Vizsla Weimaraner Whippet Yorkshire Terrier Kitty ? yes no

If no, who is not?

Please explain why that person is not in agreement.

Please indicate which best describes your current living situation: House Condo Apartment Live with parents Roommate Situation .

If you rent, list name & telephone number of landlord: (REQUIRED if renting):

What type of living environment? Rural Country Urban Suburban .

If less than two years at current residence, please list your previous address:

Aside from your immediate family, are others residing in your home? yes no

If there are others residing in your home, please provide their name(s):
and their age(s):

Does your home have a yard? yes no

Is there a fence? yes no

What type of fence and how tall?

If you do not have a fence, do you plan on building one? yes no

If so, when, and what type of fence?

Is someone home during the day? yes no part of the day .

If not, where will this companion stay while you are gone? In the house, loose Crate Separate Room Heated Garage Unheated Garage Outside

Where will this companion be kept most of the time? Select One With me/work, traveling Inside Outside Other

If kept outside, will you have a: Select One Dog Run Kennel Tie-out Other

Do you have a homeowners or renters insurance policy? No Yes

Name of insurance company:

Do you own a crate/kennel? No Yes

If so, what type and size is the crate?

If you do not own a crate are you willing to buy one and crate train this companion? No Yes

If no, please explain why:

Will you take this dog to obedience class? No Yes

If you are not willing to take this dog to obedience class, please explain why:

Have you ever owned a Mutt Airedale Terrier Akita Alaskan Malamute Cocker Spaniel American Eskimo Dog American Staffordshire Terrier American Water Spniel Australian Cattle Dog Australian Shepherd Basenji Basset Hound Beagle Bearded Collie Belgian Malinois Belgian Sheepdog Belgian Tervuren Bernese Mountain Dog Bichon Frise Black/Tan Coonhound Bloodhound Border Collie Borzoi Boston Terrier Bouvier des Flandres Boxer Briard Brittany Brussels Griffon Bull Terrier Bulldog Bullmastiff Cavlier King Charles Spaniel Chesapeake Bay Retriever Chihuahua Chinese Crested Dog Chinese Shar-Pei Chow Chow Clumber Spaniel Cocker Spaniel Collie Corgi Dachshund Dalmatian Doberman English Mastiff English Setter Irish Setter Gordon Setter Finnish Spitz Flat-Coated Retriever Fox Terrier French Bulldog German Pointer German Shepherd Giant Schnauzer Golden Retriever Great Dane Great Pyrenees Greyhound Irish Wolfhound Italian Greyhound Jack Russell Terrier Japanese Chin Keeshound Kerry Blue Terrier Kuvasz Labrador Retriever Lhasa Apso Maltese Manchester Terrier Miniature Pinscher Miniature Schnauzer Newfoundland Old English Sheepdog Papillon Pekingese Pomeranian Poodle(Standard) Poodle(Miniature) Poodle(Toy) Pug Rhodesian Ridgeback Rottweiler Saint Bernard Samoyed Schipperke Shetland Sheepdog Shiba Inu Shih Tzu Siberian Husky Silky Terrier Standard Schnauzer Tibetan Spaniel Vizsla Weimaraner Whippet Yorkshire Terrier Kitty ? No Yes

Where is that companion now?

Do you prefer a male or female companion? Female Male Either/Doesn't Matter

Why one sex over the other?

Age range you will consider for adoption: Select All That Apply Any Age Under 6 Months Up to 1 Year 1 to 3 Years 3 to 6 Years 6 to 9 Years Senior
(control/click to select more than one)

Why do you want a MuttAiredale TerrierAkitaAlaskan MalamuteCocker SpanielAmerican Eskimo DogAmerican Staffordshire TerrierAmerican Water SpnielAustralian Cattle DogAustralian ShepherdBasenjiBasset HoundBeagleBearded CollieBelgian MalinoisBelgian SheepdogBelgian TervurenBernese Mountain DogBichon FriseBlack/Tan CoonhoundBloodhoundBorder CollieBorzoiBoston TerrierBouvier des FlandresBoxerBriardBrittanyBrussels GriffonBull TerrierBulldogBullmastiffCavlier King Charles SpanielChesapeake Bay RetrieverChihuahuaChinese Crested DogChinese Shar-PeiChow ChowClumber SpanielCocker SpanielCollieCorgiDachshundDalmatianDobermanEnglish MastiffEnglish SetterIrish SetterGordon SetterFinnish SpitzFlat-Coated RetrieverFox TerrierFrench BulldogGerman PointerGerman ShepherdGiant SchnauzerGolden RetrieverGreat DaneGreat PyreneesGreyhoundIrish WolfhoundItalian GreyhoundJack Russell TerrierJapanese ChinKeeshoundKerry Blue TerrierKuvaszLabrador RetrieverLhasa ApsoMalteseManchester TerrierMiniature PinscherMiniature SchnauzerNewfoundlandOld English SheepdogPapillonPekingesePomeranianPoodle(Standard)Poodle(Miniature)Poodle(Toy)PugRhodesian RidgebackRottweilerSaint BernardSamoyedSchipperkeShetland SheepdogShiba InuShih TzuSiberian HuskySilky TerrierStandard SchnauzerTibetan SpanielVizslaWeimaranerWhippetYorkshire Terrier ?

If considering adopting a dog, will this dog be used as a guard dog? Yes No

If yes, please explain:

What other activities do you plan to do with this companion?

How many years do you plan to keep this companion?

Under what circumstances would you feel it necessary to get rid of this or any other companion?

Do you have other pets? Yes No

Other pet information:

Please list the other types of pets you have along with their age, sex and if they are spayed or neutered:


Are your other pets current on all vaccinations? No Yes

Are all of your current pets spayed or neutered? Yes No

If no, why not?

Veterinarian's name & telephone number:

If applicable, approximate date of your current pet's last office visit:

List the pets have you owned in the past ten years and what happened to them:

How did you hear about Homeward Bound Pet Rescue? Select One Newspaper Radio FNSB Shelter Word of Mouth Flyer Petfinder

List any Humane Societies, Organizations, Breed or Training Clubs with which you are associated:

We will attempt to provide you with an honest evaluation of temperament of any dog or cat available for adoption. Do you realize that often times the complete history of a dog or cat may not be known and you may encounter some behavioral problems? yes no

Are you willing to work with us on correcting these problems? yes no

Please provide the name, address and telephone number of three references:
Reference # 1:
Reference # 2:
Reference # 3:

Adopter understands that the rescue will be spayed or neutered, current on shots when they receive the rescue.

Adopter understands that there is an adoption fee of $250.00. Contact HBPRR regarding cat adoption fees.

Please leave any additional comments:

I certify that the information provided on this form is true and correct. I am also financially and physically able to care for this animal. I understand that proper food and veterinarian care can be costly and I am able to meet these requirements. I understand that a home visit is made prior to adoption and all persons living in the home and pets must be present.

By submitting this Application, Applicant agrees that HBPRR, Inc. may contact above references and veterinarian to obtain information about Applicant and their care/treatment of animals.

Applicant has read and understands the Adoption Procedures.

Your Name:
Date: