Connie's Canine Rescue
Application Form
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Email *
Name of the dog you are applying for:  *
Applicant: 
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Co-Applicant:
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Address of Applicant*: 
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City, State, Zip code: *
Phone Number*: 
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Co-Applicant Phone Number: *
Best time to contact: 
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Do you rent?: 
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Has your landlord provided written permission for you to have a dog?:
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Landlord's Name and Phone Number*:
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How Long at current residence?: 
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Applicant's Place of Employment*: 
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Co-Applicant's Place of Employment:
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Where did you hear about this dog?
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Please provide at least three personal references, and their name, phone number and relationship to you: 
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Have you adopted from another rescue before?:
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What organization and what was the animal's name?:
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Why do you want a rescue dog?: 
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How far are you willing to travel to pick up your new family member?:
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Please list all members of your household (names & ages): 
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Please list all other animals in your household (name, gender, age, breed, spayed/neutered, current vaccines?): 
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Do you have a fenced yard?:
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Type of fence:
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Does anyone in your home suffer from pet dander allergies?: 
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What treatments are/will be used to relieve these allergies?:
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If for any reason you are unable to care for the animal, who will be next in line to care for them?:
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How will you exercise your rescue dog?: 
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Have you ever owned a dog in the past for which you were the primary caretaker?: 
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If Yes, what breed? *
Have you ever sold, given away, surrendered or put down a pet?:  If Yes, explain
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Who is the Veterinarian you currently use or will plan to use?*: 
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Veterinarian Phone*: 
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List names/species/breed of all the animals this vet has treated for you::
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Will the dog mostly be inside or outside?: 
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Will the dog be allowed on the furniture?: 
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Where will the dog sleep?: 
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Where will the dog eat?: 
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How many hours per day will your dog be home alone?: 
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Where will the dog be while you are not home?:
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Are you familiar with the use of a dog crate to train/confine the dog during your absence or at night?: 
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What will you do with your dog(s) if you need to be away from home overnight or if you plan a vacation?: 
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Do you plan to train this dog to be off-leash?: 
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May we visit your home prior to the application approval?: 
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Sex preference of the dog you would consider adopting::
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Age preference of the dog you would consider adopting:

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Size preference of the dog you would consider adopting:
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Energy Level of the dog you would consider adopting:
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Breed Preference:
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First available date you will be ready to take ownership of your new family member:
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Would you consider a special needs dog that may require medication for a permanent, yet controllable condition?: 

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Is there anything you would like to add?
*In the process of doing background checks individuals may be contacted who were not given as references. 

*The information given within this application must be truthful and accurate or the application will be denied.

By completing this application you agree to the terms and conditions under which this application was written. 
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