Adoption Application: Senior Dog Rescue of Oregon, Philomath

SENIOR DOG RESCUE of OREGON
PO Box 1051, Philomath, OR 97370-9293
(541) 929-4100 Email: faria@pioneer.net

Adoption Application

* = required fields

Name:*

Address:*

Address 2 (optional):

City:*

State/Province:*

ZIP/Postal code:*

Country:*

Home Phone
(with area code):*

Cell Phone
(with area code):

Work Phone
(with area code):

E-mail Address:*

Dog's Name

Fenced yard for dog?* Yes    No

Dog will be . . . * Indoors    Outdoors    Combination

Is a human or another dog home during the day?* Yes    No

If No, how long will dog be alone?* # of hours:

Where will the dog stay when the humans are gone?*

Number of adults in home:*

Number/ages of children in home:*

Other pets?* Yes    No
If yes, please list type, age, sex, altered status,
indoor or outdoor.

Past or Current veterinarian and number.* Vet's name and phone number.

May we contact your veterinarian?* Yes    No

How much money do you think it costs to own a dog per year?*

Willing to have a home visit?* Yes    No

Willing to pay an adoption fee?* Yes    No

Willing to help w/expenses (primarily transportation if needed)?* Yes    No
Comments:

What type of dog are you looking for? Please be specific as to age, size, breed, sex, etc. The more details, the better.*

What do you want the dog for (i.e. companionship, agility, etc.)*

Would you be willing to adopt a special needs dog (i.e. diabetic, epileptic, blind, deaf, etc.)* Yes    No
Comments:

Thank you!

By submitting this application, I certify that all of the information I have provided is true and complete to the best of my knowledge.

You will be returned to the Senior Dog Rescue of Oregon main web page.



We reserve the right to refuse any applicant. Thank you for taking the time to complete this Questionnaire which helps us to make the best possible placement for all concerned.

Senior Dog Rescue of Oregon
P.O. box 1051 • Philomath, Oregon 97370-9293
(541)929-4100 •

Name:*
Address:*
Address 2 (optional):
City:*
State/Province:*
ZIP/Postal code:*
Country:*
Home Phone (with area code):*
Cell Phone (with area code):
Work Phone (with area code):
E-mail Address:*
Dog's Name
Fenced yard for dog?*	Yes No
Dog will be . . . *	Indoors Outdoors Combination
Is a human or another dog home during the day?*	Yes No
If No, how long will dog be alone?*	# of hours:
Where will the dog stay when the humans are gone?*
Number of adults in home:*
Number/ages of children in home:*
Other pets?*	Yes No If yes, please list type, age, sex, altered status, indoor or outdoor.
Past or Current veterinarian and number.*	Vet's name and phone number.
May we contact your veterinarian?*	Yes No
How much money do you think it costs to own a dog per year?*
Willing to have a home visit?*	Yes No
Willing to pay an adoption fee?*	Yes No
Willing to help w/expenses (primarily transportation if needed)?*	Yes No Comments:
What type of dog are you looking for? Please be specific as to age, size, breed, sex, etc. The more details, the better.*
What do you want the dog for (i.e. companionship, agility, etc.)*
Would you be willing to adopt a special needs dog (i.e. diabetic, epileptic, blind, deaf, etc.)*	Yes No Comments: