Date :
Name :
Address :
City :
Postal Code :
Daytime Phone :
Evening Phone :
Cell phone number :
Email address :
How did you hear about Refuge A.M.R.? :
Your home: Check the appropriate response :
Apartment
Condo
Other
Owner
Rent
Single-family home
Townhouse
If Other, Specify :
If you rent, are pets allowed? :
yes no
If yes, name and number of the owner :
Do you plan to move? :
yes no
If yes, please specify the date :
Do you have a fenced yard? :
No
Other
Yes
If no, how will you handle the exercise and the daily needs of the dog? :
If Other, please specify :
Your Family - How many adults :
What age(s) :
How many children? :
And What age(s) :
If you do not have children, do you consider having them in the future :
yes no
If yes, please specify when :
Are there any family members present at home during the day :
yes no
How many hours per day the dog will be left alone :
Does someone at home has allergies :
yes no
If yes, please specify who :
Do you currently have dogs :
yes no
If yes, how many :
Are they sterilized? :
yes no
Race, type and age of your dog? :
Do you currently have cats? :
yes no
If so, how many? :
Are they sterilized? :
yes no
General Information - How many dogs did you have for the past five years :
What happened to them? :
Type of dog you are looking for :
Preferences :
Female
Male
Age :
Where will the dog be most of the day? :
In cage
In the basement
In the fenced yard
Other
Outside attached
Outside free
Within freedom in the house
Within freedom in the house
If other, please explain :
Where will the dog be most of his/her nights? :
In cage
In the basement
In the fenced yard
Other
Outside attached
Outside free
Within freedom in the house
If other, please explain :
When your family is away from home overnight or go on vacation, what will you do with the dog :
Under what circumstances would you give up your dog :
If the dog or puppy is showing signs of behavioral problems ⃰ what will you do about it? :
Are you ready to work with a dog that might require some level of toilet training? :
Are you aware of the annual cost ** to maintain a dog? :
yes no
Do you feel you have the financial ability to do so? :
yes no
Do you agree to a home visit prior to adoption? :
yes no
Do you agree to a home visit after the adoption to ensure that the dog adapts well? :
yes no
Are you aware that rescued animals require an adoption fee ***? :
yes no
If you apply for a dog in particular, what's his name? :
Veterinarian’s name :
Veterinarian’s address :
Veterinarian’s phone number :
Please type the text below :
