First Name

Last Name

Co-Applicant

Street Address

City

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The following questions will help us determine what dog is the perfect match for your family

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

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? Yes No

If yes, please explain

How long have you lived at your current address?

Do you Own or Rent? Own Rent

Landlord's name and phone number

Do you have the permission of landlord to have a dog? Yes No

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?

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 and dimensions)

if not, are you willing 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

Please provide the full name, address, and phone number of your current veterinarian or the veterinarian(s) you used for the above listed animals

Where do you purchase heartworm preventive if not from your veterinarian?

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

Are you aware that routine costs of maintaining a dog average $500 or more a year?

Yes No

Have you sold, given away, or surrendered a pet to a shelter?

Yes No

If yes, please specify

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?

If 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 or cruelty to animals in the past?

Yes No

If YES, please specify

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?

Yes No

I/we attest that the Terms and Conditions of Adoption as stated below 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, I understand that I will be required to surrender the dog back to Agape Animal Rescue.

agree

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