Yorkie Friends Rescue Corporation
Application for Adoption
List the name of the dog in which you are
interested:_________________________
Personal
Information
Name___________________________________________
Age___________________
Spouse’s
Name___________________________________ Age____________________
Address_________________________________________________________________
City____________________________
State_____________________ Zip___________
E-mail
Address___________________________________________________________
Home Phone____________________________ Cell Phone _______________________
Employer__________________________________
Phone________________________
Spouse’s
Employer_____________________________ Phone_____________________
Number of children living at
home_____________ Ages__________________________
Other than immediate family, list all living
in your home and their ages______________
_______________________________________________________________________
How long have you lived at this address? _________ Previous address, if less than 2 yrs.
________________________________________________
Years there_____________
What is the best way to contact you? Phone
email When?_____________________
Pets
Have you ever owned a Yorkie?
______ If so, where is it now? ____________________
Do you have other pets? ______ List breed, age, and
sex_________________________
_______________________________________________________________________
Are all pets current of all vaccinations?
______ Are they spayed/neutered? ___________
If no to either,
explain______________________________________________________
Are all pets on heartworm preventative?
______ Brand _________________________
Are all pets on flea control? _______ Brand __________________________________
Groomer’s name and phone (as reference)______________________________________
Veterinarian’s name and phone (as reference)___________________________________
Approximate date of last Veterinarian visit
for each pet___________________________
_______________________________________________________________________
List
all pets you’ve owned in last 10 years, not mentioned above, and their
present status.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
General Information
How did you hear about the Yorkie Friends Rescue? ____________________
Please,list any Breed, Humane Societies, Training Clubs,
and similar organizations you support or belong
to_______________________________________________________
Please, provide the name, address, and phone
number of three professional or personal references:
_______________________________________________________________________
________________________________________________________________________
Information Specific to Adoption
Is the adopted dog
for your personal companion? ______ If not, for whom
is the dog?
______________________ We do not
adopt dogs as gifts for other parties.
Why do you want a Yorkie? ______________________________________________
Is everyone in your home agreeable to
adopting a rescue dog? _____________________
If not, who and why not
___________________________________________________
Please circle the term(s) that best describes
you current living situation:
House
Condo Apartment Modular Home
Rent
Own Living with Parents
If renting, Landlord’s name
_____________________________Phone______________
If living with parents, Parents’ Names:
____________________ Phone______________
If renting or living with other party, are
pets allowed? ___________________________
Social environment (circle one): Urban Suburban Country
Does your home have a backyard? ______ Is it fenced? ______ Fence type___________
Fence height______ Will gate be padlocked?
______ Is fence permanent? ____________
Is edge of fence buried to prevent tunneling?
______
Do you have a swimming pool or hot tub at
your home? _________
Does it have a safety fence around it to prevent dogs or children
from falling in? __________
Will dog be left alone during the day? ______
For how long? ______ Days per week____
Where will the dog stay while you are gone?
___________________________________
Specifically what will be the dog’s living
situation? (Examples-run of house, confined to one area, garage or
basement)______________________________________________
Will the dog be crated? _______ If so, for how long? __________ How often? ________
Have you ever adopted any animal before?
______ Explain________________________
From what agency did you adopt?
_____________________ Phone_________________
Do you prefer: male or female? __________ Age range? _______ Size? ____________
Do you understand that often times the
complete history of a rescue dog may not be known? ______ Will you be willing
to work with us to correct any possible behavior problems? ______
Social/Behavioral problems you could not
handle: Circle all that apply:
Soiling floor Dog/cat aggression Excessive barking Other
_____________________
Will you take the dog to obedience training?____ If so, where? _____________________
Will you always maintain necessary vaccinations
for the dog? _________ Provide
necessary veterinary care and treatment? __________ Have annual hw
test? _________
Maintain regular heartworm & flea
prevention? __________
Medical condition(s) you are not able to
handle__________________________________
Are you willing to keep the dog for life?
______
Under what circumstances would you give up a
dog? _____________________________
What activities do you plan to share with
your dog? ______________________________
_______________________________________________________________________
Veterinarian you will employ, name, address,
and phone__________________________
________________________________________________________________________
Are
you willing to pick up the dog at the foster home or to assist with the
transport if the dog is a long distance from your home? ________ What maximum
distance could you travel (one way)? ___________________________ (We do not
ship dogs.)
List any other comments:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Please
Read Carefully Before Signing and Submitting Application
I certify that the
information provided on this form is true & correct. I am also financially
and physically able to care for this animal. I understand that proper food and
veterinarian care may be costly, and I am able to meet these requirements.
Phone or personal interviews are conducted after the receipt of the
application, then vet, groomer, and other references are checked. I give
permission to contact the references provided on this application. Please
inform your groomer and vet that we will be calling them for information about
you. If they require you to sign a release in order to give a reference for
you, you must do so before we call them. If the vet or groomer refuses to give
a reference for you because you have not signed a release, it may result in
denial of adoption. Home visits are made prior to adoption and may be done on a
random basis following adoption. If, upon inspection, we find that information
contained in this application to be false or substantially incomplete, Y
Signature:
_________________________ Date:
_____________________
We require a hard copy of your signature prior to adoption certifying the above
information. You may also print the form out and mail it, with your signature
to:
Yorkie Friends Rescue Corporation
c/o Vicki Ham
Revised 02/09/08
