Please do not submit applications via moble phoneas we will not receive it. Thank you!
If you are applying for a dog on the ACC Euthanasia list,please use the Death Row Dog form.
Today’s Date: ...
Dog Choice #1:
Dog Choice #2 (optional):
Dog Choice #3 (optional):
Dog Choice #4 (optional):
Please list any preferences (age, sex, breed, color, personality)
Adoption Fee Agreement Yes No
Please print identification information clearly, especially email address:
First Name:
Last Name:
Maiden Name (if applicable)
Address:
City:
State:
Zip Code:
Email: *
Place of Employment:
Since (mo/yr):
Home Phone:
Work Phone:
Driver's License Number *
Would you like to receive our newsletter? Yes No
How did you hear about our rescue?
For whom are you adopting the dog?
Choose One: Self Gift Other Family Member
Why do you want to adopt a dog?
Who will be the main caregiver of the dog?
What do you think are the most important responsibilities in owning a dog?
Have you submitted an application with another organization for a dog at this time? Yes No
Have you ever had an application declined for adoption of an animal from an animal welfare group/animal control facility? Yes No *
If Yes, please explain:
Your Age:
Do you live with: Spouse/Partner Roommates Parents Alone
How many people live in your home?
Are there any children in the household, including “part-time” children? Yes No
If yes, what are their ages?
How many adults (21 and older) in your household?
How far would you be willing to travel to pick up a pup?
If needed, would you pay for or assist with shipping expenses?
Does any member of the family have any allergies to animals?
Describe the kinds of personal situations where you might have to return your adopted dog, i.e., job loss, children, move, marital change, etc.:
What would you do if you could not keep the animal? Please be specific:
If you move, will you take the dog?
Do you or anyone smoke in the house?
Are all parties involved on board and willing to help with the care of new addition? Yes No *
Pup's living situation (check all that apply) Pup will be house pet, living inside with family Pup will in basement or garage Pup will live outdoors Dog house provided Guard Dog for: Business Guard Dog for: Residence
How many hours a day will the pup be home alone?
When home alone, the pup will be (check all that apply): In a crate Wire cage Pup pen inside In a Kennel Outdoor Indoor
Tied up outside: Cable Run With a chain None of the above
Pup will be loose:
Pup will be: Indoor Outdoor *
Other - please specify:
How will you exercise the pup? Leash walks every day Will have cable or pup run in the yard Will be free to run in fenced yard Will have access to unfenced yard Will be free to roam around (Off leash and unsupervised in unfenced area) Will bring to dog-park (Public area where pups can run and play together off-leash)
Other:
Where will the dog sleep at night?
Home Setting: Urban Suburban Rural
Yard size: Small Medium Large Acreage
If so, height, length, and type of fence:
Your home is: House Apartment
Do you own the property? Yes No
How long have you lived at this address? If less than 1 year, please also list prior address.
If you are renting, please provide Landlord's name and phone number for verification:
If your land lord allows dogs, is there a weight/size/breed restriction? Yes No Don't know
If “yes”, what is their restriction?
Does your municipality have breed specific restrictions? Yes No Don't know
If so, please describe the nature of the restrictions:
Do you have other Pets living with you now? Yes No
If Yes, please list in box on right including pet's name:
Name
Type
Age
Sex
Was the pet Spayed or Neutered?
Primarily Indoor or Outdoor?
What year did you get the animal?
How did you acquire the animal?
Year deceased (or last year you had pet)?
Cause of death, or where pet is now (detail)
Name of vet you will use for your new pet:
What kind of veterinary care do you plan to provide?
Have you considered the extra expenses that will come with having a dog including vet care, food, supplies and equipment, toys, training and boarding? Please explain:
Are you willing to take the time to housebreak a dog, and do you understand that changing a dog’s environment may cause the dog to have accidents? Yes No
If you are applying for a puppy/dog who is not housetrained, how will you housetrain the dog?
If a behavioral problem arises, what steps will you take to work on it?
How would you discipline the dog?
What will you do if the dog gets into trouble by ruining something you value?
Will you take obedience training?
Have you ever obedience-trained a dog before?
Will the dog ride in the back of a pick-up truck, tethered or untethered? Yes No
Are you familiar with heartworm disease? Yes No
If yes, how would you prevent it?
List the types of behavior problems you consider NOT acceptable:
At what point would you consider humane-killing (euthanasia), should your dog become ill?
Of all the breeds available why do you want to adopt a Pit Bull?
Experience: Please relate any prior experience you have had with this breed:
By checking YES you agree to absolve Pibbles & More Animal Rescue and all of its representatives from any liability in reference to a pup featured in this web site. Yes No
By checking YES you agree that the pup will not be used in any illegal activities nor be found at any time in a municipality where Pit Bull presence is illegal. Yes No
By checking YES you agree that the pup is to be kept as a house pet. It shall not be sold for medical or experimental purpose, and it shall not be used for breeding. Yes No
By checking YES you agree that if you are chosen to adopt the pup, you will review and agree to an adoption contract, which is wholly in the pup’s best interests. Yes No
By checking YES you agree that if you ever need to relinquish the animal during its life, you will contact Pibbles & More Animal Rescue for its surrender. Yes No
By checking YES, we have permission to contact these references Yes No
By checking YES, you agree to provide a copy driver’s license with operator’s license number visible or photo ID with ID number visible Yes No
By checking YES, upon approval, do you agree to provide the license plate # of your vehicle Yes No
Please supply the name and phone number of your current veterinarian, or the one who saw your previous pet(s), with their title identification.
Veterinarian’s Name, address and phone number: "Please make sure that YOUR name and phone number are on the vet's records/files (contact them prior to submitting this application to us, if need be). Otherwise they will NOT be able to locate your records and give us a reference for you, and we will not be able to process your application."
Vet Reference
1st Reference
2nd Reference
3rd Reference
Please tell me why you are interested in adopting a dog and a little about your lifestyle:
I have read the above information carefully and have filled out this application honestly. I understand that omission of information and/or failure to answer all questions and sign the application can result in this application being declined. Also, if an omission or untruth is discovered after an adoption takes place, I understand that the Pibbles & More Animal Rescue reserves the right to annul the adoption and reclaim the animal. If the application passes this review, I agree to a home and yard visit on a mutually agreed date by a Pibbles & More Animal Rescue volunteer or a courtesy visit through another reputable rescue before an adoption decision is made.
In addition, I understand the adoption decision is dependent on many factors, including but not limited to the compatibility of the family and home to the individual animal, and other applications received on this animal. I understand it is the organization's prerogative to decide which home is most appropriate and that their decision is final.
Signature(s) *
Date *
Printed Full Name(s) *
Captcha (please enter the characters you see in the box to the right before submitting app)
Thank You for filling out our Adoption Application!
