ADOPTION APPLICATION & AGREEMENT
NOAH'S bARK PET RESCUE, INC.

Adoption Application

Adopting a pet is a lifelong commitment that should be taken seriously. We strive to match lifestyles with pet personality, special needs and breed type so that you and your pet will benefit from a healthy, fulfilling relationship. Please fill out this questionnaire completely and return it to a Noah's bARK representative. Applicants must be 21 years or older. We reserve the right to refuse an application without stating cause.

*** We do not place our pets with families outside the State of Georgia.***

Which pet are you interested in?
Name:			Age:
Spouse:			Age:

Address:
City:			State:		Zip:

Telephone (Home):        (Work):        (Cell):
Email:
Drivers License State:
Drivers License #:
Occupation:
Employer:
Time Employed with this Employer:  less than 1 year 1 year 2 years 3 years 4 years 5 years 5-10 years 10-15 years 15-20 years more than 20 years

1.) Why do you want to adopt a pet?

2.) Do you live in: apartment    rental home own home   condo   mobile home    with my parents

3.) If you rent, do you have the landlord's permission to own a dog? Yes       No

Name of complex:

Landlord:

Security Fee: $

Contact Number:

Pet Deposit: $

4.) How often have you moved in the past 5 years?

5.) Suppose you move to an apartment or rental that does not accept pets, what would you do?

6.) Does anyone in the household smoke?(some dogs are allergic) Yes No

7.) Do you foresee any major changes in your life in the next 15 years, (average life span of a dog), such as marriage, children, health problems, going away to college?
Yes No

If yes, please explain:

8.) Do you have a fenced in yard with no gaps? Yes No If so, how high, what kind?

9.) Number of adults in household? Relationship to you?

10.) How many children live in the household?

Age	Gender
	Male Female
	Male Female
	Male Female
	Male Female
	Male Female
	Male Female
	Male Female

11.) Do all family members know of your plans to adopt a pet? Yes No

12.) Do any family members have animal allergies? Yes No
If yes, please describe:

13.) Enter the age and type of pets currently in your household?

Age	Kind of Pet

14.) Do any of your pets currently live mostly outdoors? Yes No
Please describe:

15.) Are current pets spayed/neutered? Yes No

16.) Where do your current pets sleep? (Be specific?)

17.) Are you able and willing to exercise the dog on a regular basis? Yes No
Method:

18.) Where do your current pets stay when home alone? (Be specific)?

19.) Have you always kept a collar and ID tag on your pets at all time? Yes No

20.) How many pets have you owned in the past? Where are those pets now? Be specific:

21.) Have you ever had a serious behavior problem with a previous pet? Yes No
If, please describe.

22.) Were all previous pets spayed/neutered? Yes No

23.) Do you know what heartworm disease is and how to prevent it? Yes No

24.) Is your current dog, (or was your previous dog), on heartworm prevention medication? Yes No

How often and which brand?

25.) How do you plan to prevent fleas and ticks?

26.) How do you feel about spaying or neutering your pet?

27.) How many hours will your new dog be home alone on typical day?

28.) Where will the new dog stay when home alone?

outside in fenced area

outside in dog pen

free run outside

in crate

outside on a chain, tie-out or runner

in the garage

in the basement

"baby-gated" in kitchen or other room

free run of house

other:

29.)Where will your new pet sleep at night?

In crate

In basement

Doghouse with tie-out

Doghouse with a fenced area

In one room of the house

Free run of house

In garage

On the floor in your bedroom

In child's room

Free run outside

In the kitchen

Other:

30.) What percentage of time will the new dog spend inside of house? %

31.) Do you have a doggie door? Yes No
Would you consider putting one in? Yes No

If "No", please explain:

32.) What would you expect vet care, heartworm and flea preventative to cost yearly? $

33.) What type of housetraining procedures will you use?

34.) Under what circumstances do you think it is OK to let a dog outside unattended? (Please select all that apply)

In a quiet subdivision

In the mountains

When the dog knows home and comes back when called

On a lot of acreage

Whenever the dog wants

Only in a secure fensed in area

In an invisable fenced area

Other:

35.) For which of the following reasons would you give up your dog? (please select all that apply)

moving	not housebroken
divorce	gets too big
shedding	not getting along with other pets
allegies	behavior problems
barking	increased work hours
aggressive	medical problems
new baby	not getting along with children
getting out of fence	none
children lost interest	other:

36.) Have you ever given a pet up? Yes No

If so, please explain the circumstance:

37.) What type of pet food do you intend to feed your pet?

38.) Has a dog died on your premises of distemper, parvo or unknown causes? Yes No

39.) Suppose your pet develops a medical problem that becomes expensive, (some treatments can cost thousands of dollars).

What would you do?

40.) Suppose your pet develops a frequent urination problem at the age of 12. You work 8 hrs a day and he can't hold it that long. Do you:

Have him put to sleep because he is older

Baby-gate him in a place where the flooring is not carpeting

Put in a doggy door

Give him to a rescue group or shelter

other:

41.) If you date or marry someone who does not like or want your pet(s), what would you do? Please elaborate:

42.) How do you feel about dogs being on the furniture?

43.) If you are adopting a dog with longer hair, will you groom this dog? Yes No   
How often?

44.) How did you hear about us? Radio Newspaper Web Site Word of Mouth TV Other

45.) Have you ever looked at or applied for a pet with another rescue group? Yes No   
How long ago?


Did you adopt? Yes No

Please explain:

46.) Do you object to an unannounced home visit by a representative from our organization? Yes No

47.) Please list your Veterinarian's name: Phone number

48.) Please provide the name, phone number and address of 3 personal references NOT related to you:

Name	Phone Number	Address

NOAH's bARK Pet Rescue, Inc. is adopting to you, a pet that is believed to be in good health. Any known physical or behavioral problems will be disclosed to you. NOAH's bARK Pet Rescue, Inc. assumes no responsibility for properties of yours or others destroyed by a NOAH's bARK adopted animal. Neither does NOAH's bARK Pet Rescue assume responsibility for bites or injuries inflicted by this animal. You, as the adopter, have a right to return or exchange the adopted animal, within 30 days of the adoption date if the animal becomes ill or is unsatisfactory as a pet. We will exchange the pet for you within this time frame. Adoption fees are not refundable. If it becomes necessary to relinquish this pet, at any time, the adopter will give Noah's bARK Pet Rescue the first right to reclaim this pet.

By clicking on "Submit" below, I am attesting to the truthfulness of my answers. Falsification of any of the above information will be grounds for disallowing the adoption of said rescue dog and possible removal of said pet from my home.