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:

Type of dwelling:

House

Condo

Apartment

Other 

Do you:OwnRent
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? 

Approximate 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!