First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Cell Phone*

What is the name of the dog(s) that you saw on our website/Petfinder that you are particularly interested in?*

Have you or a family member applied with us before?*

Have you or a family member adopted from us before?*

Please list age and relationship of all people living in your home (even part time), including applicant.*

What type of home do you live in: Single family, town home, apartment, farm, etc.?*

When the dog goes out, how will they be supervised?*

Please describe your household: Active, Noisy,Quiet, Average?*

If you rent, please give the rules governing pets and the landlord’s name and number: (By providing this information you are allowing us to contact your landlord please inform them of this call so they will speak with us) *

Do you live in any designated area that has BSL law? The banning of 'Pit" or "Pit Mix" such as an HOA contract, condo, apartment or live within a county or city limits having additional restrictions or registrations for ownership of such breeds?*

Is everyone in agreement with the decision to adopt dog?*

Does anyone in the family have a known allergy to dogs? *

Is your yard fenced and if so how much area and what type/height of fence?*

Do you have time to provide adequate love and attention? *

What other pets do you have (specify type, age and Pets name) *

Are your dog(s) current on Heartworm Prevention? *

What brand of Heartworm Prevention do you give?*

Where do you purchase your Heartworm Prevention?*

Are these pets up to date on vaccines? *

Are these pets spayed/neutered? If not, why?*

Have you every surrendered a pet? If so, why?*

Have you ever had a pet euthanized? If so, why?*

Have you ever lost a pet to an accident? Explain*

How do you discipline your pets and why?*

Do you have a regular veterinarian? *

Veterinarian’s name: *

Clinic Name:*

Clinic Address:*

Clinic Phone Number:*

Name Records Are Under: *

How long have you used them? (Less than 3 years please provide prior vet information also.) Vets Name: Clinic Name and address: Phone Number: Name on Records: (Providing us with this information you are allowing us to call your vet. Please call your vet and ask them to authorize the release of information to us.) *

What is your idea of an ideal dog and why? *

Desired age: *

Desired adult size:*

Desired breed: *

Breeds you would not adopt: *

In a few words, tell us what you know about this breed.

What about this specific dog interests you

Regardless of the dogs age at adoption, are you willing to adopt a dog that has a partial or full need for potty training?*

Desired sex: Spayed Female, Neutered Male, No preference*

Would you consider adopting: An outgoing dog?*

Would you consider adopting: A hyper dog?*

Would you consider adopting: A shy dog?*

Would you consider adopting: A dog that takes daily medications(s)?*

Would you consider adopting: A dog that requires additional training?*

Would you consider adopting: A dog that requires regular grooming?*

Would you consider adopting: An older dog?*

Would you consider adopting: a "nippy" dog? *

Would you consider adopting: a dog that barks a lot?*

Would you consider adopting: litter mates?*

Where will the dog spend the day? (describe)*

Where will the dog spend the night? (describe) *

Number of hours (average) dog will spend alone and how? (describe) *

Who will have primary responsibility for this dog's daily care? *

When the dog goes out, how do you plan to supervise it? Fenced yard, how large? *

Who will have financial responsibility for this dog? *

Do you agree to provide regular health care by a Licensed Veterinarian? *

Are you willing to let a representative visit your home by appointment? ___Yes ___No*

Do you agree to contact us if you can no longer keep this dog? __ Yes __No *

Would you be interested in fostering? Yes, No, would like to know more *

Name and location of Employer:*

Can we contact you via your provided cell phone number - via text or call regarding your application? *

By initialing here, you understand all members of NW Arkansas Rescue of Canines will make your safety our top priority. However, we are not liable for any injuries sustained to you, your children or animals while visiting our facility.*

Thank you for choosing NW Arkansas Rescue of Canines. Could you please tell us how you heard about our rescue? Thanks!