Name:____________________________________________________

Date of Birth: _____________________________________

Spouse:__________________________________________________
Address/City/State/Zip/: ___________________________________________________________________________
Home Number:__________________________
Work Number:__________________________
Cell Number:___________________________
Email Address:________________________________________________
Do you Own or Rent Your Home? __________________________________________
Do you have a completely fenced in yard or do run? __________________________________________________________
If you do not have a fence, how do you plan to confine the pet to your yard?
_____________________________________________________________________________________________________________________
_____
Do you have children at home? ______________
What are their ages?____________________________________________________
What pets do you currently own? ___________________________________
Please list their names, ages, breed
_____________________________________________________________________________________________________________________
_____
Vet Reference:, including address and phone number: (We will be checking with your vet before we call you so this
information is very important).
_____________________________________________________________________________________________________________________
_
Are your pets vaccinated? ____________ Are your pets on heartworm prevention? ______________
Have your pets been spayed or neutered? _______________ If no, why not_________________________________________
Are other members of your family aware that you want to adopt an animal? ________________________________________
Is anyone in your family allergic to animals? ___________________________________________________________

Is the animal going to be a gift for someone? ______________

How did you hear about us? (internet,newspaper, TV, Radio) _________________________________________
Please let us know what you are looking for in a pet OR which of our rescues (size/sex/age/breed):
___________________________________________________________________________________________________________
Please describe what a typical day will be for your new pet. ______________________________________________
Where will the dog spend most of the day & if you plan to kennel? ______________________________________
Where will the dog sleep @ night? ________________________________________________________________________
How many hours a day will the animal be left alone? _____________________________________________________
What behaviors would you consider unacceptable in your pet? _____________________________________________
How would you correct these behaviors?___________________________________________________________________
Please list at least 2 references, including name and telephone number:
___________________________________________________________________________
___________________________________________________________________________

Thank you for your interest in one of our homeless pets! Many of our animals were pulled from less than ideal
circumstances and therefore we want only the best for them in their new homes. Our adoption process is thorough.
Your answers will be reviewed and your vet and personal references will be contacted. We will contact you by phone as
quickly as we can with the results of your application review.
We, the adoptive family, agree to provide a safe home for _________________where they will be treated as a family
member. We acknowledge that dogs require annual vet visits, dental care, vaccinations and additional attention when
ill. We agree to keep this pet on monthly heartworm, flea, and tick preventative, as well as keeping an ID tag with
name and phone number on the pet at all times.
We have been informed that the dog is a rescue and M.A.S.H does not know the previous health history other than the
results on the current records. We will not hold M.A.S.H or any of its representatives responsible for subsequent vet or
any other bills. We will not hold M.A.S.H liable for problems resulting from the animals behavior. The adoption fee is
non-refundable, this money goes 100% to pay for all the foster dogs care immediately.
Signature of the adopting persons:
_____________________________________________________
Signature of representative of M.A.S.H.:

Date: ___________

_______________________________________________________

Date: __________

Thank you for giving a second chance to a rescued animal!!