First Name*
Last Name*
Address*
City*
State/Province*
Zip/Postal Code* -
Email*
Home Phone
Work Phone x
Cell Phone
Alt Email
Text/Pager Email
Spouse/Co Applicant Name *
Enter your age and the age of co-applicant*
Please list you Employer/Spouse Employer and a contact number*
Please list the names and ages of any children living in your home, or "None" if there are no children in your home.*
If you don't have children, do you plan on having children someday? (Choose N/A if you listed children above)
Does anybody else live in your home? If Yes, please list their names and ages.*
Does any household member suffer from asthma or allergies? If yes, please describe.*
In what type of home do you live?
Type of Environment
Do you rent or own?
If you rent, please enter your landlord's name and phone number. If you own, please enter "N/A".
If you rent, have you received the approval of your landlord to have an animal? If you own, please enter "N/A". Choose one: Yes No N/A
Is your yard fenced?* Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced
Is there a chance that you might move in the next 10 years?
If so, are you willing to restrict your choice of housing to places where a dog is allowed?
Which dog/s are you interested in?* Choose an animal: Artemis Bindi Black Jack Blitz Bolt Brittle Brownie Chester Chewy Cooper Dixie Rose Ernie Faith Floppy Gideon Gracie Gray Hansel Holly Hope Jasper Jax Jif/aka Sir Jiffy Smuckerton Joy Jules Kevin Libby Marty Maverick Mickey Mork Nugget O'Dell Olivia Peaches Peanut Petra Pointer Prim Remylynn Riku Scully Sebastian Shadow Sid Stanley Tarzan Taylor
What traits are you looking for in a pet
Where will the dog be kept?
Where will the animal sleep at night?*
How much time will the animal spend alone during the day*
Where will the animal be kept when you are not home*
What behavior would you not be able to tolerate?
Do you understand that the dog will take time to adjust to its new surroundings and that certain behavioral issues might occur?
Are you willing to work with the dog to correct these issues?
Under what circumstances might you want to return the dog? (Examples: Marriage, new baby, divorce, behavior issues, financial stress, job change etc.)*
Will you take your new dog to a basic obedience class? This is required for ALL puppies and some adult dogs.*
Veterinarian's Name and Phone Number (or N/A if you do not currently have a vet, or have not had one recently).*
Do you have any pets currently? If yes, please list name, age, sex, species, and breed.*
Are your current pets on heartworm and/or flea preventative? If no pets choose N/A
Are your pets current on all shots? If no pets, please choose "N/A".
Are your pets spayed/neutered? *
List all the pets you have owned in the past 10 years and what happened to them:*
Where do your currently owned dogs stay when you are not home?
What do you enjoy most about dog ownership?*
What do you like least about dog ownership?*
Please list the names and email address or telephone #'s of 3 references not related to you. If you do not currently have pets under vet care please provide a fourth reference.*
Have you met with PMR volunteer, at local event, who did you meet with. Have you met any of the dogs you may be interested in?*
Have you applied with any other rescue? If yes, please list* Choose one: Yes No N/A
I certify that the information entered on this applicant is true. Enter your name and date*
