CONTACT PERSON

Have you ever applied with Polka Dogz Pet Rescue?
YesNo
[group previous-group clear_on_hide]When?[/group]

Have you ever been convicted of a felony?
YesNo
[group felony-group]

[/group]

Have they ever applied with Polka Dogz Pet Rescue?
YesNo

When?

Have they ever been convicted of a felony?
YesNo

ADDRESS

HOME ENVIRONMENT

Do you own or rent?
OwnRent

Do you have a property management company, landlord or rental office?
YesNo

Do you have a fenced yard?
YesNo
[group fence-group clear_on_hide]

[/group]
Do you have a pool?
YesNo
[group pool-group clear_on_hide]
Does it have a child safety fence around it?
YesNo
Could a small dog get out of the pool on its own?
YesNo
[/group]
How many people live in your home?

Do you have children under 18 living in your home?
YesNo
IF YES:

PET OWNERSHIP HISTORY

Have you ever had a dog that you returned or re-homed to somewhere else?
YesNo
IF YES:

Do you have any pets currently?
YesNo
IF YES:

Have you had any pets in the past?
YesNo
IF YES:

IF YES:
Please provide your most recent veterinarian information

Are your current pets, or were your previous pets, spayed or neutered?
YesNo
Are your current pets, or were your previous pets, on heartworm prevention?
YesNo

REFERENCES

Reference 1




Reference 2




Reference 3

PET CARE

If you can no longer care for your pet, who will?

What is your employment status?


How will you discipline your dog?

Where will the dog stay while you are home?

Where will the dog stay when you are NOT home?

Where will the dog stay if you go out of town?

Where will the dog sleep?

How do you feel about a dog being on the furniture?

Do you require that the dog you adopt is already house-trained?
YesNo
IF YES:

Are you looking for a dog that is already crate trained?
YesNo
IF YES:

Have you ever been charged with animal neglect or abuse?
YesNo
IF YES:

Are all people in the household ready for a new dog?

DOG REQUEST

What dog are you applying for?

How did you hear about Polka Dogz? Please be specific.

I certify that all answers made by me on this adoption application are, to the best of my knowledge, true and correct.
YesNo