I understand that the adoption fee is $175

Last Name   First Name   Middle Initial

Co-Applicant

Permanent Address

City   State Tennessee Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other   Zip

Home Phone   Work Phone(s)

Cell Phone   Email Address

Is there a specific dog from our website that you are interested in?

Have you previously applied for a dog with Agape? Yes No  —  If yes, which dog?

What is your family's activity level? High Medium Calm

Ages of all family members

Who will care for, train and exercise the dog?

Who is the dog primarily for? Child Adult

Does anyone in your household have allergies? Yes No  —  If yes, to what allergens?

Have you ever been convicted of a felony or misdemeanor? Yes No

If so, please explain

How long have you lived at your current address?

If you rent, what is your landlord's name and phone number

Do you have the landlord's permission to have a dog? Yes No   —  Any weight or breed restrictions?

Will the dog be allowed inside the house? Yes No

How long daily will the dog be left alone (without humans)?

Where will the dog stay when you are away from the house?

May we visit your home prior to application approval? Yes No

If Yes, when?

Please list all the pets you have owned in the past five years — include the species, name, sex, if they are spayed/neutered, and what happened to the pet

Are you familiar with the use of a dog crate to train the pet during your absence or at night? Yes No

Is your yard fenced? Yes No

If yes, please describe your fence:

Type   Height   Width   Length

If you do not have a fence, do you have any plans to install one? Yes No

Approximate size of dog's yard area:

Will the dog be walked daily? Yes No

Will the dog be exercised in a fenced yard? Yes No

Will the dog be allowed to run free without supervision? Yes No

Will your dog receive formal obedience training? Yes No   —  If yes, who is your trainer?

Please provide your current veterinarian information, or a previous clinic used for the above listed animals

Clinic   Name of Vet   Phone

City   State Tennessee Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other   Zip

Where do you purchase heartworm preventive?

If no veterinary reference available, please list two personal references that we may contact

Name   Relationship   Phone

Name   Relationship   Phone

Are you aware that routine costs of maintaining a dog average more than $500 a year? Yes No

Have you sold, given away, or surrendered a pet to a shelter? Yes No   —  If yes, please specify below

Please tell us a little of your lifestyle and your family, including any special activities in which your dog would be included:

What are you looking for in a new dog for your family?

When you move what will you do with your dog?

Do you understand the state and local ordinances concerning licensing? Yes No

Do you understand the state and local ordinances concerning leashing? Yes No

Have you, or any member of your family/household been cited for leash law violations or cruelty to animals in the past?

Yes No   —  If yes, please explain

How did you hear about Agape Animal Rescue?

If this adoption is approved will you allow Agape to place a picture of you and your new animal in the "success stories" section of our web page and/or general marketing materials?

Yes No

I/we attest that the Terms and Conditions of Adoption as stated above have been read in full by me/us and I/we understand that is part of the adoption process and will be enforced. I/we attest that the information provided on this application is true and accurate to the best of my/our knowledge. If any of this information is not true and I am approved for a dog, I understand that I will be required to surrender the dog back to Agape Animal Rescue.