PLEASE NOTE: Completing this application is merely the first step towards adopting a

dog. By submitting this completed application, you are neither guaranteed nor obligated to
adopt. This is merely the beginning of a process that will include vet references, phone interviews and home
visits.

Date:

First Name:

Last Name:

E-mail Address:

Street Address:

City/Town:

State:

Zip Code:

Home Phone:

Work Phone:

Cell Phone:

Best Time to Call:

Occupation(s):

How long have you lived at your present address: (years / months)?

Do you rent or own your home?

*Please note that renters must include documentation from the renter that dogs are allowed to live in this
dwelling.

Do you have a fenced-in yard?

Fence Height?

If you move what will you do with this pet?

Where will the pet be kept during the day?

During the night?

When no one is home?

When on vacation?

On average how long will this pet be left alone each day?

Does anyone in the household have allergies to dogs?

Who will be responsible for this pet?

Which brand of food will you be feeding this pet?

Please provide name and contact information for your veterinarian, or the one you will use with this pet:

Vet:

Clinic Name:

Address:

Phone Number:

Reference #1:
Name:

Address:

Phone Number:

E-mail Address:

Reference #2:

Name:

Address:

Phone Number:

E-mail Address:

Please list all the types of pets you have owned in the last five years:

Please list all types of pets (cat, dog, etc.) including breed, age and gender that currently live in the household:

Type/s:

Breed/s:

Age/s:

Spay or Neuter?

Gender?

Do you use heartworm preventative?

Do you use flea and tick preventative?

If you have lost a pet or it died at an early age or due to an accident, please provide details:

If you have ever given up a pet or put one to sleep, please provide details:

If you have ever surrendered a pet to a shelter or rescue group before please provide details:

How much money do you plan on spending on this pet each year (food, vet, boarding, toys,
etc.)?

Describe your reason for wanting to adopt a dog:

Would you be willing to accept a dog with some health problems?

Would you be willing to accept a dog that is not housetrained?

Would you be willing to accept a dog with some behavior problems?

Would you consider adopting a senior dog?

Explain the size, sex, color and personality of the dog you prefer to adopt:

What age range would you consider adopting?

LIST ALL ADOPTERS RESIDING IN THE HOUSEHOLD (include yourself and children in the household):

Name/s:

Age/s:

Relation/s:

If no children are listed above are there plans for children in the future?

How many children VISIT your home and what are their ages?

Have you filled out an application with other rescue organizations?

COMMENTS:

By submitting this form you are certifying that all information contained above is true and correct. That you
are over 18 years of age and the person responsible for making pet decisions in your family. That you are
looking to adopt a pet, give it a good and loving home as a pet owner and accept full responsibility for his/her
care.
I agree to abide by all state and local pet control laws. I understand it is my responsibility to become
familiar with these laws.

Signature:
___________________________________________
Date:

____________________

The next step is to provide your Rescue Agent with this completed adoption application by emailing it or mailing
it back to the address below. Your application will be reviewed and if additional information is needed you will
be contacted and a home visit will then be scheduled.
Cari Smith
carimcsmith@yahoo.com
4136 R Street Omaha, NE 68107
402-917-3070
Greg Franks

gregd@nopetsleftbehind.com

Papillion, NE 68046
402-350-9939