Piece Of My Heart Rescue Adoption Application

Completing this application does not obligate you or us in any way. We match each acceptable applicant with our dogs to ensure a successful adoption for both the dog and the individuals looking for their next 4-legged family member.

Name of the dog you are interested in:

Contact Information

Your Name:
Home Phone:
Work Phone:
Cell Phone:
Street Address:
Are you adopting for someone else? Yes/No:
If yes, for whom:

Tell us about you and your home

Name/ages of all human members of your household:

Does everyone in the home agree to this adoption?:
Do you often have visitors to your home? Yes/No:
If yes to visitors: How often?
If yes to visitors, are there any grandchildren or other children? Yes/No:
If yes to children: What are their ages?
Who will care for the dog and where will he/she be kept?:

Where will the dog be while you're at work?:
How many hours will the dog be left alone?:
Who will take care of the dog while you work?:
Where will the dog sleep?:
What food will you be feeding?:
Have you owned pets in the past? Yes/No:
What breeds and how long did they live?:

Do you currently own other pets?:
Name species, breed, age of each.:

Type of residence?:
Do you own or rent?:
If renting, does the landlord agree to this adoption?:
Name of apartment complex:
Landlord name & phone #:
Do you have a yard?:
Is it fenced?:
Fully or partially?:
Type of fence:
If no fence, how will you exercise and potty the dog?:

Are there stairs in your home?:

Are you willing to...

Learn the proper care and treatment of this dog?:
Take the dog to the vet when ill and for yearly exams?:
Return only to Piece Of My Heart Rescue for any reason?:
Maintain heartworm preventative for the dog's entire life?:
Do everything possible to give the dog a long and healthy life?:
Assume financial responsibility?:
Adopt a dog older?:
Adopt a dog abused?:
Adopt a dog unreliable with children?:
Adopt a dog handicapped?:
Adopt a dog that requires medications?:
Adopt a dog that requires house-training?:
Take the dog for obedience training if needed?:
Accept the special needs, time and patience required with a rescue dog?:

Are you...

Familiar with the the breed of this dog for which you are applying?:
Aware that rescue dogs can have health and housetraining problems?:
Familiar with necessary shots and heartworm tests and preventative?:
Familiar with flea and tick treatment and preventatives?:

And finally...

Why do you want to adopt at this time?:

List reasons why this dog would not be suitable for your home:

Your veterinarian's name, address & phone:

Your groomer's name, address & phone (if applicable):

Anything else you'd like to add:

If are not contacted by one of our members within 36 hours of submitting an application, please email janisjunkie@hotmail.com
** Depending on your email settings, our member's response may be in your "junk" or "spam" folder because of an unknown address. **

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