Nuts for Mutts
How did you hear of us?
Name and Phone No. of Veterinarian
Address of Veterinarian
Personal Reference (Non-relative) Name
TELL US ABOUT THE DOG YOU HOPE TO ADOPT
Specific dog you are interested in
Breeds of dog you are interested in
Why do you want to adopt a dog?
How many hours a day will the dog be
Where will the dog be kept when alone?
What kind of food will you feed your
dog? (talk to us about Flint River Ranch)
If not already housebroken, how will
you housebreak your dog?
Do you have a fenced yard?
TELL US ABOUT YOUR HOUSEHOLD
Do you currently have other pets?
If so, please list name, age, sex and
Are your pets up to date on heartworm
prevention and vaccinations? (If not,
please explain why)
Are your current pets spayed/neutered?
(If not, please explain why)
Have you owned animals in the past
not listed above? (If yes, please explain
what became of them)
How many children in your household?
Please list names and ages of all co-
habitants or others who frequently
share your premises
Do you own or rent your home?
If renting, please provide landlord
name and contact information (This is
required information for all renters)
Comments and other information you would like to share:
I, the undersigned, hereby certify that all statements made herein make full disclosure and are true.
There has been no event or information not disclosed in writing which could reasonably be expected
to have an adverse effect on the health, comfort, safety or well-being of a dog. I am aware that my
application must be approved before any adoption can take place. Such approval will include, at a
minimum: contacting my personal and veterinary references, contacting my landlord (if applicable)
and a home visit by a Nuts for Mutts Rescue volunteer.
Nuts for Mutts Rescue, Inc., P.O. Box 16795, Rochester, NY 14616 ~ Email: firstname.lastname@example.org