First and Last Full Legal Name, No Nicknames Please

Street Address:

City, State and Zip Code:

Area Code and Home Phone:

Area Code and Work Phone:

Area Code and Cell Phone:

REQUIRED - Email Address:

What Breed Are You Considering Adopting ?:

What Age Range Are You Interested In ?:

Dog Interested In More Information About:

Will This Be Your First Pet ?

Yes
No

If This Is Your First Pet, What Vet Have You Chosen:

Your Vet's Street Address:

Your Vet's City, State and Zip Code:

Your Vet's Area Code and Phone Number:

Your Living Situation ?

Home
Farm/Ranch
Condo
Apartment
Mobile Home

Do You Own Or Rent ?

Own
Rent

If You Rent, Please Provide Your Landlord's Name

Your Landlord's Street Address

Your Landlord's City, State and Zip Code

Your Landlord's Area Code and Phone Number

Number Of Adults In The Home ?

One
Two
Three
Four or More

Number Of Children In The Home ?

None
One
Two
Three
Four or More

Children's Ages Starting With Youngest

Number Of Other Pets In The Home ?

None
One
Two
Three
Four_or_More

Breed, Age and Gender of Other Pets

Is Your Yard Fenced ?

Yes
No


Your Current Veterinarian:

Your Current Vet's Street Address:

Your Current Vet's City, State and Zip Code:

Your Current Vet's Area Code and Phone Number:

Are Your Current Pets Up To Date On All Shots ?

Yes
No


Are Your Current Pets Spayed or Neutered ?

Yes
No


Are Your Current Pets on Heartworm Prevention ?

Yes
No


What Type of Heartworm Prevention ?:

Where Do You Keep Your Current Pets During The Day ?:

Where Do You Keep Your Current Pets During The Night ?:

How Many Hours A Day Are Your Current Pets Left Alone ?:

How Many Hours A Day Do You Anticipate A New Pet Will Be Left Alone ?:

Please Provide a Minimum of Three References, Name, Address
and Phone Number with Two Being Non Family Members:

We Often Get In To Care "Special Needs" Pets, Either With Physical Restrictions
or Health Problems.  Are You Interested In A "Special Needs" Pet ?

Yes
No

Clicking the "submit" button below certifies that the above information is accurate and true and that I have read, understand and agree with the terms of Heavenly Acres Pet Rescue's Adoption Policy.  I hereby decree that I am financially, physically and emotionally capable and am committed to properly care for any animal adopted from Heavenly Acres Pet Rescue.  If any information provided by me, in this submitted application, is found to be untrue, I also understand and accept that the animal adopted from Heavenly Acres Pet Rescue can be removed from my possession without a refund if neglect or abuse is evident.

Comments ?

Before submitting, please  CHECK  and make sure  ALL  fields are filled in using n/a if a question does not
apply to you.  Incomplete Adoption Applications can  NOT  be processed and will be automatically deleted.
Thank You....

Date Application Submitted: