Name of dog you wish you adopt:
*
Today's Date
*
APPLICANT INFORMATION
Primary Phone
*
Email
*
Date Of Birth
*
City
*
State
*
Zip/Postal Code
*
Country
*
Length of time at this address:
*
Employer
*
Occupation
*
Length of time at current employer:
*
Work Schedule (Be Specific):
*
RESIDENCE INFORMATION
Do you own a home, rent a home, or live with family?
*
Own Rent Live with family
If "Rent," provide Landlord/Management's name & contact information:
*
If "Rent," provide any animal, breed, weight, or size restrictions:
*
If "Yes," to HOA/Community Association Co, please provide name & contact information:
*
What type of home do you live in?
*
Single Story Multiple Story Twin Townhouse Condo Apartment Other
If "Other," type of home please explain:
*
If Apartment:
*
Private Complex N/A
If "Yes fenced-in" please describe type of fence:
*
HOUSEHOLD INFORMATION
Name(s) & age(s) of all other adults living in the household:
*
Name(s) & age(s) of all children living in the household. Please include children living part-time or weekends
*
On average, how many hours a day will the dog be left alone?
*
0-2 3-5 5-8 8-10 10+
On average, how many days per week will the dog be left alone?
*
0-1 2-3 4-5 6-7
What areas of the home will the dog be allowed into?
*
What areas of the home with the dog NOT be allowed into?
*
Where will the dog be kept at night? If "Other," please explain:
*
How long are you going to allow the new pet to adjust to his or her new home?
*
If the animal gets lost, what will you do?
*
Pet #1 - Type Of Animal/Name
*
Pet #1 - Breed
*
Pet #1 - Age
*
Pet #1 - Amount Of Time Living With You
*
Pet #2 - Type Of Animal/Name
*
Pet #2 - Breed
*
Pet #2 - Age
*
Pet #2 - Amount Of Time Living With You
*
Please include information for any additional pets still living with you:
*
Please list any pets that you have had within the last 5 years. Include name of pet, type, & amount of time living with you:
*
Reason pet(s) are no longer living with you:
*
Reference #1
*
Reference #2
*
If approved by another shelter, please list name:
*
If "Yes," (you have given up an animal) please explain why & where the animal went:
*
If your dog/pet were to survive you, what would happen to them?
*
Who would assume responsibility of the dog? Is this person aware of this and in agreement?
*
Please provide any additional information about yourself, your past experience with dogs, and why you feel you could provide a good home for a rescue animal:
*
If "Yes," please explain:
*
EMERGENCY CONTACT INFORMATION
Email
*
How did you hear about Bubbas Station Rescue?
*
If you are human, leave this field blank.