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 Adoption Application 

You may also download it here
if you'd like to complete it and send it back via email to


We have the right to refuse adoption to anyone if we feel the home is not the right home for a particular animal.
All applications will be followed with a home inspection prior to adopting the dog. 

General Information About You & Your Household
Your First and Last Name:
Co-Applicant's First and Last Name:
Email Address:
Home Phone:
Work Phone:
Cell Phone:
Who will be the primary caregiver of the dog?
Is primary caregiver over 21?


Complete answers to the following will help us match your specific needs and expectations.
Name of the dog you want to be considered for:
Description of the dog:

Why are you interested in this particular dog?

We receive many applications for each dog, and may already be in the process of approving another home for the dog in which you are interested.  If this dog is unavailable do you want us to match you with a suitable companion?  YES  NO

Would you consider a special needs dog, one who requires medication?  YES  NO

Will you accept a mix?  YES  NO

Desired Activity Level:  High Medium Calm 

Gender Preference:  Male Female Either

What age range would you like to adopt? Under 1 year 1 yr-3 yrs 3-6 yrs 7 yrs and up Any Age

Please list ALL persons living with you or visiting often (age and relationship).
For your peace of mind, you need only list ages of children and need not include their names.

Is everyone in your household in agreement about adopting this dog?  YES  NO

Does anyone in the household have any animal allergies? NO YES If Yes, to what allergens?

May we visit your home prior to application approval? YES  NO

If yes, when is best?

Information About Your Home

How long have you lived at your current address?

Which of the following best describes your current residence? (Check one)
House   Apartment   Duplex   Mobile Home   Condo   Townhome
Do you rent or own? Own   Rent/Lease

Landlord's Name and Phone Number

Many landlords require a significant non-refundable pet security deposit.
If you rent, do you have your landlord's permission to have a dog? YES  NO    
If so, up to what size?  Permissible Size/Weight

Will the dog be allowed in the house?   YES  NO

How long daily will the dog be left alone (without humans)?

Where will the dog stay when you are away from the house?

Do you have an exercise area in your yard that is completely fenced in?  YES  NO
Please describe the rough dimensions of the enclosed area and height/material of fencing.

If you do not have a fence, will you install one?    YES  NO

Please list any improvements to the dog area that need to be made.  How long will this take?

Will the dog be walked daily?   YES  NO

Exercised in a fenced yard?   YES  NO

Ever allowed to run free without supervision?  YES  NO

Will your dog receive formal obedience training?  YES  NO

Are you aware that routine costs of owning a dog average and often exceed $500 per dog per year?   YES  NO

Information About Your Experience With Pets

Please list all the most recent pets you have owned in the past:

Species (dog/cat) Sex Spayed/Neutered

What happened to the pet? Please add pet's name (for our vet check)


Please tell us about your past experience with dogs in general.  What type and size dogs?  Include any special training or activities.

Do you currently have any other pets?   YES  NO
What kind? What size?  Please describe them, including species, age, gender, personality traits and spay-neuter status.

Have you ever had to give up a pet?  (For example: Sold a pet, given away or had to give away or take to a shelter)
Please explain why and when.

Will you allow the dog on your furniture?   YES  NO

Will you allow the dog on your bed?   YES  NO

Please tell us why you want a dog.  Describe your "ideal" dog.

Please tell us a little about  your lifestyle, your family including any special activates in which your dog would be included.  (If you have any requirements or requests for a dog, please let us knows so that we can more carefully match a dog to your lifestyle.)

If you move, what will you do with your dog?

Do you understand the state and local ordinances concerning licensing and leashing?  YES  NO

Have you, or any member of your family or household ever been cited for leash law violations or cruelty to animals in the past?  YES  NO

If yes, please provide details.

When you go on vacation, who will care for your dog and where will it be cared for?

What do you like most about having a dog?

What do you like least about having a dog?

Vet References

Please provide the full name, City State and phone number (very important) of your current veterinarian:

Who is your local veterinarian? 
Vet's Complete Address 
Vet Phone Number (including area code)
Vet records are under the name of

Are your pets current on all vaccinations?   YES  NO

Where do you purchase heartworm preventative? 

Brand of heartworm preventative? 

Please identify any other veterinarians that you have used recently? Name and Phone Number please, including area code.


Do you understand that completion of this application does not guarantee that you will be approved to adopt?  Do you further understand that completion of this form is only the first step in the adoption process and that, should you wish to complete this process, an in-home screening will follow?  YES  NO

Do you understand that Circle Of Hope K9 Rescue requests a donation of an amount agreeable to both parties and that this donation is used to care for other dogs in our rescue?  YES  NO

As part of the adoption process and before placing any dog, you will be asked to sign a contract in which you agree to certain conditions, such as allowing a rescue representative to visit your home prior to and after placement of the dog, and surrender the dog back to Rescue if you violate the contract in any way.

Are you willing to sign and be bound by such a contract?     YES  NO

1/we arrest that the information provided on this application is true and accurate to the best of my/our knowledge.  I/we understand that completion and submission of this application does not guarantee adoption of a dog.  YES  NO

Thank you for taking the time to complete this questionnaire.  Circle of Hope K9 Rescue has only the best interest of the dogs in mind and sincerely wants to adopt each dog to the family best suited to it. Are there any other comments you'd like for us to consider when reviewing your application?  

Additional Comments:

Clicking the Submit Button will return you to our website.

Submission of an application does not guarantee placement of a dog.

This website is currently under construction.

Circle Of Hope K9 Rescue
Serving Western Tennessee and New England.
Please visit our other website at

Copyright 2010 Circle Of Hope K9 Rescue

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