Countryside Animal Rescue
Dog Adoption Application Online

Countryside Animal Rescue takes our animals very seriously. This application is a thorough attempt to let us know if the animal you have an interest in will be a good match for you and your family.We want the Adoption process to be a pleasant and rewarding experience for You and your new pet.

We will make a home visit prior to acceptance of your adoption application. We feel strongly that we are seeking a forever home for these animals and do not want to put the pet at risk in a bad situation, nor do we want a family to take on more than they are capable of dealing with financially or emotionally. Our home visits are only done to make certain that you are able to provide a safe, secure and loving environment for the animal.We are not looking at your housekeeping abilities and practices. Please note that Countryside Aimal Rescue reserves the right to place or not to place any particular animal into any home and an approved application gives not right to any animal.

Please fill out the application below completely. Be sure to answer ALL the questions. If the question does not apply, simply leave it blank. Some of the questions may take some time and thought – take your time in answering. Thank you for considering adopting an animal from Countryside Animal Rescue

Pet Information
Application Date:
Animal ID# AN:
Animal Name:
Personal Information
Name:
Address 1:
Address 2:
City:
State:	Zip:
Home Phone:	Example: 555-555-5555
Work Phone:
Cell Phone:
Alternate Phone or Fax:
Best time(s) to call:
Home E-mail:
Work E-mail:
Occupation:
Length of time at current job:
Your Gender:
Your Age:
	How many adults (21 & over) are in your home?
	How many people under 21 are in your home?
If any, specify ages:	Separate ages by a comma.
I live with:
Living Arrangements and Lifestyle
Dwelling Type:
If other, please specify:
	Own Dwelling Rent If you rent,
Landlord's Name:
Landlord's Address:
Landlord's City, State, Zip:
Landlord's phone:	Example: 555-555-5555
	How long have you lived at your current address?
Yard Size:
If acreage, how many?
Yard Fenced?
Describe Fence Type:
Fence Height:
	Does your homeowners Association, city, County or State have breed-specific restrictions?
	Your main reason for wanting an animal?
If Other, please specify:
Housebreaking preference:
	Exercise is important for animals. Consider your activity level. Do you want your pet to be:
	What level of training would you prefer for the dog?
Other specific requirements?	The more information you provide, the better we can help you in choosing an animal that is a good fit with your family and livestyle.
	Have you checked with your insurance company to see if the dog breed you are interested in adopting will be covered if a claim is filed? Yes No
Animal's Living Situation
	What best describe's the animal's living situation?
	If other, please specify:
	How many hours each day (average) will the animal be home alone?
	When home alone, the animal will be:
	If other, please specify :
	Animal exercise plan:
	If other, please specify:
	Where will the animal sleep at night?
	If other, please specify:
	What type of collar do you plan to use on this animal?
Other Pets
	Do you have other animals currently? None Dog(s) Cat(s) Other
	If other pets, please specify type:
No. of cats:	Ages:
No. of cats micro-chipped:
No. of dogs:	Ages:
No. of dogs micro-chipped:
No. of spayed females:
No. of un-spayed females:	If not, why?
No. of neutered males:
No. of un-neutered males:	If not, why?
Please specify breed(s) dog(s) in the home.
	Are all your pets up to date on vaccines? Yes Yes
If not, why?
	Do you use flea prevention on your current pets? Yes No
If not, why?
Flea Prevention Used on Dogs:
Flea Prevention Used on Cats:
	Have cats in your household been tested for Feline Leukemia and FIV? Yes No If not, why?
If so, when:
Results:
	Have dogs in your household been tested for Heartworm annually? Yes No
When:
Results:
	If not testing annually for heartworm, why?
What brand of food do you use or plan to use?	(Note: We recommend feeding a premium food for better nutrition and health for your pet.)
	Have you had other animals prior to your current one(s)? Yes No
	If yes, why are they no longer with you?
	If other, please specify:
If yes, please specify what type of pets and how many.	Other than the animal you are applying for, do you plan on adding any additional pets to your home? Yes No
	Are you aware of pet insurance? Yes No
	Have you previousely had pet insurance? Yes No
Name of Company:	(With any adoption made through Countryside Animal Rescue, you will receive a free 30-day pet insurance policy, compliments of PetFinder and the ShelterCare Insurance Company.)
Breed Experience and Information
Why did you choose this breed?
Specify your prior experience with this breed:
	Have you ever surrendered a pet before? Yes No
	If so, why?
	What might prompt you to consider returning the animal? Please be honest. We want the adoption experience to be a pleasant one for both you and your new animal.
	If other, please specify:
	If your animal developed behavioral problems that you could not resolve, would you consider paying for a consultation with a private trainer or behaviorist? Yes No Please Explain:
	Are you prepared for the additional time, cost and trouble it might take to obtain animal friendly housing if, or when, you move? Yes No Please Explain:
	Are you prepared to deal with the emotional and /or physical problems that many rescued dogs have? Yes No
	Are you willing to commit to any special requirements that a rescue dog that you adopt may need, such as a special diet, medication, etc.? Yes No
	If you find that you can not meet the requirements of a rescued dog that you adopt, will you agree to return the dog to Countryside Animal Rescue? Yes No
	Are there any specific traits you would like your new animal PARTICULARLY to have? Please Explain:
	Are there any specific traits you would like your new animal NOT to have? Please Explain:
	How do you plan to provide for your animal's basic annual medical care?
	If other, please specify:
	How much do you expect to spend annually on your animal's basic medical care?
	What specific things would you expect that amount to cover? Check all that apply. Vaccinations
	Heartworm Testing and Prevention
	Flea Control
	Internal Parasite Testing & Treatment
	Other - Specify:
	If the animal you havve applied for is not a good match for your lifestyle, would you be willing to consider other animals? Yes No Please Explain:
References Required
Name of Your Vet or Clinic:
Vet Phone:	Ex. (555-555-5555)
Vet Address:
Vet City, State, Zip:
	How long have you been a client of this vet?
Please provide at least two(2) personal references.
Referral Name 1:
Phone:	Ex. (555-555-5555)
Address:
City, State, Zip
Relationship:
Referral Name 2:
Phone:	Ex. (555-555-5555)
City, State, Zip::
Relationship:
Is there any other information you would like to provide?
	How did you hear about Countryside?
	If other, please specify:
	Please understand that a rescue animal can come from unknown backgrounds. Although we will never purposely put you or any member of your family at risk, by entering your initials in the space provided below, you agree to assume the risks of being bitten, scratched, or injured while visiting with this animal being considered for adoption. Please enter your initials:
	I understand that the recurring cost of maintaining any animal can exceed well over $200 per year for vet bills, vaccinations and routine care. By entering my initials below, I agree to perform all routine health maintenance annually for my adopted animal and any other unknown veterinarian care that could arise after adoption. Please enter your initials:
	By entering my intials in the space provided below, I confirm that the information listed on this application form is accurate and true to the best of my knowledge. Please enter your initials:

Countryside Animal Rescue Dog Adoption Application Online

Countryside Animal Rescue
Dog Adoption Application Online