Basset/Pug Lovers Rescue
Adoption Application

First Name*:	Last Name*:
Home Phone*:	Work Phone:
Cell Phone:	Street Address*:
City*:	State*: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhoda Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming
Zip Code*:	Email Address*:
Do you own or rent your home? Own Rent	If you rent, are pets permitted in your lease? Yes No
Please indicate weight limit, if applicable:	Is your yard fenced? Yes No If not, are you willing to install a fence? Yes No
Landlord's Name:	Landlord's Phone:
Landlord's Address:
Type of Home: Single Fam. Duplex Condo Townhouse Apartment Farm	If there are children in the household, what are their ages? No children Under 2 yrs. 2-5 yrs. 6-10 yrs. 11-15 yrs. Over 15 yrs.
How did you hear about us?	How many adults in your home including you?
Do you plan on moving in the next 6 months? Yes No	Would your pet go with you if you moved? Yes No
List animals you currently own or that are in your care/house and those you have owned in the past five years, if you need more room list in comment box below: Dog Cat Name Male Female Spay/Neuter Yes No Housed Inside Outside Both How Long Owned? Where is it now? Dog Cat Name Male Female Spay/Neuter Yes No Housed Inside Outside Both How Long Owned? Where is it now? Dog Cat Name Male Female Spay/Neuter Yes No Housed Inside Outside Both How Long Owned? Where is it now? Dog Cat Name Male Female Spay/Neuter Yes No Housed Inside Outside Both How Long Owned? Where is it now? Dog Cat Name Male Female Spay/Neuter Yes No Housed Inside Outside Both How Long Owned? Where is it now? Dog Cat Name Male Female Spay/Neuter Yes No Housed Inside Outside Both How Long Owned? Where is it now?
What is your motivation for getting a Basset/Pug at this time:
Which Basset/Pug are you interested in adopting?
Who will be responsible for this Basset/Pug?
Is anyone in the household allergic? Yes No	Would you adopt a special needs dog/puppy (ie. blind, timid, 3 legged) Yes No
Where will this Basset/Pug be kept while you are away from home?
Who will be responsible for this Basset/Pug while you are on vacation?
Would you still be able to care for this Basset/Pug if your home or family situation changed (divorce, relocation)?
Have you ever given away/sold or released an animal to a shelter or rescue group? Yes No
If yes, why?
Will you provide annual vaccinations and any necessary medical care? Yes No
How many hours a day will this Basset/Pug be alone?
Where will this Basset/Pug be kept during the day?
Where will it be kept at night?
Vet's Name:	Vet's Phone:
Vet's Address:
Comment box for additional pertinent information:
"If a Basset/Pug is being abused, neglected, not getting proper medications or vet care and/or if it is not inside it must be kept on leash with owner it cannot be left loose or unattended. If outside; dog must be in a fenced area at all times or on leash. Any violations will result in the Basset/Pug being picked up and returned to Basset/Pug Lovers Rescue with no return of adoption fees and with no liability for medical bills or any other expenses you may have incurred." This information will be printed right on your signed application. This is a legal, binding document and will be used in a court of law if necessary (at your expense).I have signed this contract, with the knowledge that I must abide by these terms. I fully understand and agree to all the terms of this legal document and will pay all court costs if I do not abide by it and a lawsuit is initiated against me. *You must check that you have read and agree to this contract (contract will not be processed without your agreement) *Yes - I fully understand and agree to ALL the terms of this legal document. *No - I do not agree to ALL the terms of this legal document (your application will not be processed if you answer no to this question).
Signature*:	Date*: