NCCR Adoption Application Form
Please complete entire application.  You must be at least 21 years old to adopt. 
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Name of dog that you are interested in:
When would you would be ready to take the dog/puppy home?   *
I would prefer: *
Required
Breed/mix preference?: *
Size when full grown? *
Required
Male/female? *
Energy level? *
Housetrained required or willing to train? *
Your name: *
Date of birth (please note you must be at least 21 years old to adopt): *
Are you: *
Required
Street address: *
Town, State and zipcode *
Telephone #   and  Work #: *
Email address: *
Maximum number of hours pet will be alone daily: *
NAME(S) of each adult in your home: *
Age(s) of children in the home: *
Age(s) of children that visit frequently: *
Have children been around dogs before? *
Required
Why do you want to adopt a dog? *
Required
How many pets have you had in the last 10 years? *
Type of pet and pet's name *
Age of pet and if spayed/neutered *
How long have (did you have) pet? *
If you no longer have pet, why not? *
Type of pet and pet's name
Age of pet and if spayed/neutered
How long have (did you have) pet?
If you no longer have pet, why not?
Type of pet and pet's name
Age of pet and if spayed/neutered
How long have (did you have) pet?
If you no longer have pet, why not?
List additional pets and their information.
Provide your vet's name and phone number. Please call your vet to give your permission to release information to the NCCR adoption counselor.  We are unable to complete processing your application if we are unable to speak with your veterinarian. *
Are your pets kept inside or outside? *
Where are your pets kept when you are not home? *
Required
Does anyone in your home have allergies to dogs? *
Do you rent or own?  If you rent, you must provide landlord's name and phone number. *
Is your yard fenced? And if so, what type of fence? *
Are you able to leash walk your dog? *
How will you correct inappropriate behavior?   *
How will you "housebreak" your dog if he/she is not housebroken? *
Have you ever given a dog or puppy away? *
Required
If you have given your pet away, please provide details. *
Have you ever had an animal taken away from you by dog control or animal control? *
Required
Have you ever applied for a dog from NCCR before? *
Required
Have you ever adopted a dog from NCCR before? *
Required
Could we arrange a time for a home visit? *
Required
List three (3) references including phone numbers where references can be reached in the evening. Please include the email address for your references whenever possible.                                                                                                                  If you do not provide references or if we are unable to reach your references, we will be unable to complete the processing of your application. Your references must include at least one neighbor and a co-worker or friend.   *
Please list any behavior problems you could not tolerate:
Please tell us anything you would like us to know about your family or the ideal dog that you are looking for.
Where did you hear about Northern Chautauqua Canine Rescue?
Signature and date:
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