Name of the dog you're applying for:
Name:			Partner's Name:
Address:			City:
Prov/State:			Postal/Zip Code:
Home Phone#:			Accept Collect Call:	No Yes
Email Address:
Can we call you at work?	No Yes		Best time to call:
Living Situation:	House Condo Townhouse Apartment Mobile Home Other		If 'Other', Please Describe:
Do You:	Rent Own Other		If 'Other', Please Describe:
Landlord's Name:			Landlord's Number:
Environment Type:	City Suburban Country		Number of years there:
Your Employer:			Phone:
Job Title:			Employed Since:
Spouse Employer:			Phone:
Job Title:			Employed Since:
Number of children:			Gender:	NA Female Male Both
Ages:			Does anyone have any allergies? If so, please explain:
Others residing in home?	No Yes		If yes, their ages:

Home Sq. Footage:			Approx Yard Size:
Is there a part of your home the dog will not have access to?	No Yes		If yes, please explain:
Does your yard have a fully enclosed/fenced yard?	No Yes		If yes, describe the fence (height, secured underground, invisible, etc.):
Is there a gate?	No Yes		If yes, can it be locked:	No Yes
If there is no fence and gate, please describe how you will keep your dog secure on your property:
Is someone home during the day?	No Yes		Where will your dog be kept during the day?
Where will your dog be kept during the night?			How many working hours will your dog be left alone in a day?
How often do you go away on holidays?			Where would the dog stay during holidays?
Will you have a dog run/dog house?	No Yes		Under what conditions would you use it?
Will you take your dog to obedience class?	No Yes		Which trainer do you plan to use?
What activities do you plan to do with your dog?			Who will be the primary caregiver of the dog?
What do you plan to feed your dog?			What is the maximum you would spend for medical treatment which would maintain a good quality of life?
Do you plan to get pet insurance?	No Yes		Who would immediately care for your adopted dog should you become ill or die suddenly?
Why do you want a rescued dog?			How many years do you plan to keep the dog?
Under what circumstances would you give up the dog?			Are there any behaviors that the dog may exhibit that would prompt you to give it up?

Which of the folling best describes the dog that you are looking for?
Age	Baby (0 - 6 months) Puppy (6 mos - 1 year) Teen (1 - 2 years) adult (2 - 7 years) Senior (8+ years) No Preference		Size	Toy (< 10 lbs) Small (11 - 25lbs) Medium (26 - 60lbs) Large (> 60lbs) No Preference
Activity Level	Minimal Moderate Active Very Active No Preference		Coat	Smooth coat Short Medium Long No Preference
Gender	Female Male No Preference		Are there any specific personality attributes that you are looking for in a dog, such as dominant or passive?
Do you have a breed preference? If so, please list.			Have you ever owned this breed before?	No Yes
Are you prepared to have regular grooming done if the breed requires it?	No Yes
Have you ever owned a dog before?	No Yes		If so, where is that dog now?
Do you have any other pets?	No Yes		If yes, please list type/breed, age, sex
List other pets you have owned in the past 10 years and what happened to them:			Where did your current and previous pets come from?
Are your other pets current on all vaccinations?	No Yes		If yes, approx date of pet's last visit:
Are your other pets spayed/neutered?	No Yes		Do you use heartworm prevention with your other pets?	No Yes
If so, what type?			If not, why not?

How did you hear about LOYAL Rescue?			Have you applied to adopt a pet with any other organizations or rescues in the past year?	No Yes
List any humane societies, organizations, breed or training clubs you are associated with:
We will attempt to provide you with an honest evaluation of the temperament on any dog we have to place. Do you realize that at often times the complete history of a rescue dog may not be known and you may encounter some behavioral problems?				No Yes
Are you willing to work with us on correcting these problems?				No Yes

References

Please provide the name, relationship to you, address and phone number of three personal references (maximum of one family member) as well as your veterinary reference. If you have no previous veterinary history, please include a fourth reference (not a family member).

Reference 1

Name:			Relationship:
Phone:			Email:

Reference 2

Name:			Relationship:
Phone:			Email:

Reference 3

Name:			Relationship:
Phone:			Email:

Reference 4

Name:			Relationship:
Phone:			Email:

If the dog you are applying for is no longer available, would you like us to keep your application on file?	No Yes
Alternatively, would you like to continue with the interview and home visit process to attain the 'approved' status should another dog meet your needs come into LOYAL's foster system in the next six months?	No Yes
I have contacted my vet and references already:	No Yes
I have read the FAQ section of the LOYAL Rescue website.	No Yes
I am aware that a fixed adoption donation and a signed adoption agreement apply should I be the successful applicant.	No Yes
I certify that the information provided on this form is true & correct. In signing this document I am granting permission for a LOYAL Representative to contact all stated references & veterinarian(s). I am also financially and physically able to care for this animal. I understand that proper food, water, shelter, and veterinarian care is necessary & may be costly, and I am able to meet these requirements. Home visits are mandatory prior to adoption and are made on a random basis following adoption. If upon inspection we find that information contained in this application to be false, we retain the right to turn down your application or remove the animal from your premises without a refund of monies paid. We reserve the right to refuse an applicant due to our primary interest being the well being of the animal. We require a hard copy of your signature, at the point of adoption, certifying the above information.
I Agree and I certifity that I am 18 years or older