DOG ADOPTION APPLICATION

Thank you for your interest in adopting a dog from Close to Home Animal Rescue! We appreciate your time and honesty in filling out this application. This will help us find the perfect match for your family/household.

Name of dog you are interested in adopting & why:

What attracted you to this dog:

Name:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Best Time to Call:

Email:

Personal References: (other than family members) who are familiar with your experience as a pet owner

Reference 1

Name:

Relationship:

Years know:

Phone Number:

Alternative Phone:

Email:

Best time to call:

Reference 2

Name:

Relationship:

Years know:

Phone Number:

Alternative Phone:

Email:

Best time to call:

Do you live in a:

If Other Please Explain

Do you own or rent your home? --Select-- Own Rent

How long have you lived at this address?

If renting, do you have your landlord's permission to adopt an animal? --Select-- Yes No

Note: If there is a limit on the number of pets you are allowed, please note the limit on the copy of the bylaws. If adopter resides in housing which is rented, adopter is responsible for any and all security deposits and/or additional monthly rent incurred and must be paid to landlord prior to adoption

Landlord's Name:

Landlord's Phone:

Do you have a fully fenced in yard or kennel area? --Select-- Yes No

Fence height:

Fence Size:

Fence Type:

If no fence, how will you handle the dog's exercise and toilet duties?

How many adults in household?

How many children in household?

Ages

Do any family members have allergies to animals? --Select-- Yes No

If yes, please explain:

Are all family members in agreement about adopting a puppy mill/shelter rescue and the extra work and patience that goes into it? --Select-- Yes No

Any other animals in home? --Select-- Yes No

Do you have a regular veterinarian? --Select-- Yes No

Vet Full Name:

Vet Address:

Vet Phone Number:

How long have you been with this vet?

Do you give CHAR permission to contact your vet? --Select-- Yes No

If no Vet Reference, please provide a reason:

For all pets you presently own, give name, age, sex, breed and if spayed/neutered:

Give name, age, sex, breed, if spayed/neutered, and what happened to all pets that you have owned in the past 10 years, but no longer have, listing the years you owned them:

Are there regular visitors to your home (human or animals) with which your new pet must get along?

If yes, please explain:

In your research of puppy mill dogs, is there anything about these dogs' potential issues that might be an issue for you? Please describe:

Check all plans for this animal:

Please explain Other:

Are you applying to adopt for yourself or a gift for someone else? --Select-- Self Gift

Where will the pet spend the day? --Select-- Loose Indoors Crated Bsmt Garage Kennel Fenced Yard Other

Please explain Other:

On average, how many hrs will the pet spend without human company each day:

Where will the pet spend the night? --Select-- Loose indoors Crated Bsmt Garage Kennel Fenced Yard Other

Please explain Other:

Do you understand that CHAR will have the pet spayed/neutered (unless too young)? --Select-- Yes No

Do you agree to license this dog and give it regular health care? --Select-- Yes No

Do you agree to contact CHAR if you can no longer keep this dog? --Select-- Yes No

If you had to move from your home, what would you do with your animals?

Would you be willing to allow CHAR to visit your home? --Select-- Yes No

If no, why?

How did you hear about our rescue efforts?

Are you over 18 years of age? --Select-- Yes No

If the pet you have applied for is no longer available, please describe what you are looking for in a rescue dog.

Gender: --Select-- Male Female Either

Color Preference:

Age:

Breed:

Size:

*If approved for adoption you will need to bring a collar, leash or crate to pick up the pet.*

Close to Home Animal Rescue (CHAR) does ask an adoption fee in order to help us cover expenses incurred. Prices on different animals may vary depending on age and veterinary expenses we have incurred.

All of the above information I have given is true and complete. Should an unsprayed/unneutered animal be placed with me due to age, I agree to have it spayed/neutered by such date agreed upon by me and a CHAR representative. At that time, I will forward evidence to CHAR that such procedure has been completed.

This animal will reside in my home as a pet. I will provide it with quality food, water, shelter, training, affection, and medical care. I understand that most CHAR animals are puppy mill/shelter rescues, and that the animals available for adoption may have habits, temperament, or physical conditions not yet known at the time I adopt that animal. While all CHAR animals have seen a vet, some issues surface later and I understand that it is my responsibility to evaluate the animal for myself before agreeing to adopt it.

I am in full agreement with these terms of adoption. CHAR shall not be liable for, and is hereby relieved from, all liability for any damage, expenses, causes of action, fines, suits, demands, judgments or claims of any nature whatsoever arising from or by reason of any damage to property or injury to any persons caused in whole or in part by the animals placed in your home. I hereby accept and assume such liability and agree to protect, indemnify and hold CHAR harmless from and against all of the aforesaid. Submitting this form constitutes your permission for us to check references.

WE RESERVE THE RIGHT, IN OUR SOLE DISCRETION, TO REFUSE ANY APPLICANT FOR ANY REASON.

Yes, I have read the disclaimer and agree to these terms & conditions (required)

Upon submitting this form you understand that you are allowing CHAR and it's representatives to check the references contained herein, and are hereby giving granting your permission for them to do the same. Submission of this form also indicates that all of the answers contained in this document are true to the best of your knowledge. (required)