Adoption Application

  All fields are required

Full Name:
Email Address 1:
Street Address:
Email Address 2:
Home Phone:
Cell Phone:
Work Phone:
Fax Phone:

Name of the pet(s) you are interested in: 

What attracted you to this particular pet(s): 

Are you familiar with the breed(s) that we believe this pet to be?   Yes   No

    If yes, how? 

Are you willing to spend the time and share the space to properly care for this animal during it's lifetime?  
Yes   No

Rescue animals have sometimes been in neglectful and/or abusive situations and; therefore,
may experience difficulty making the transition to a new forever home. Are you willing to be
patient while the animal adjusts to it's new home?   Yes   No

What is your current living arrangement?
House Apartment Duplex Mobile Home Condo Other:

How long have you lived at this address?  

Do you own or rent?   Own   Rent    If you rent, does your lease allow pets?   Yes   No     

 If applicable, please provide:  Landlord Name  Phone Number

Please list the following information for all persons living in your household (including self):
Name Age Occupation Interests Work Schedule

Who will be the primary care taker of the pet?

How many hours per day, on average, will the animal be left alone?

Will the animal be kept: Inside    Outside

Where will the animal be kept during the day (be specific)?

Where will the animal be kept during the night (be specific)?

Where will the animal be kept when you are at home (be specific)?

How will the animal be taken care of when you are out of town (be specific)?

Do you have a fenced yard? Yes   No     Type of Fence:  Fence Heigth:

If you do not have a fence, how will the animal be exercised & allowed to relieve itself?

Is this your first experience as a pet owner? Yes   No

Up to Date on Shots?
Heartworm Preventative
& Type?
Yes No
Yes No
Yes No   Type:
Yes No
Yes No
Yes No   Type:
Yes No
Yes No
Yes No   Type:
Yes No
Yes No
Yes No   Type:
Yes No
Yes No
Yes No   Type:

Phone Number
Phone Number

Routine veterinary care for your pet can be very costly. What preventative veterinary care are you willing & able to
provide for this animal?

If you move, what will become of your pet?

If you are no longer able to care for or keep your pet for any reason, what will you do with your pet?

We at WSRMI have observed this pet and have provided you with all of the information we know to be true about this animal.
However, it may take several days or even weeks for this pet to fully adjust to its new environment.
Does this present a problem for you? Yes   No

If yes, why?

Please list the names and phone numbers for three references. Please list at least two non-family members:
Name Relationship Phone

Why do you feel you would provide a good home for a rescue animal?

Please take a moment to add your comments. This information may help us to make a determination about
your approval/denial:

Our adoption fees are NON-REFUNDABLE and NON-NEGOTIABLE. If for ANY reason the adoption does not work out the dog MUST be returned to Westie/Scottie Rescue of Martinsville.

Furthermore, I also realize that if any of the information I have provided proves to be false,
the adoption will NOT take place. Do you agree? Yes   No


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