Rescue Me-Purebred K9 Rescue, Inc by m6Dv2G0


									                        Rescue Me-Purebred K9 Rescue, Inc.
                               of Central New York
                   Donna Foley, Adoption Coordinator – (315) 271-5234
                        Mary Cooper, Director – (518) 763-9211

As a non-profit animal welfare group, our goal is to promote responsible animal care and prevent
the abuse and suffering of companion animals. We will personally screen applicants in order to
determine if the needs of a specific rescue animal fits the lifestyle expectations of the potential
owner. This method has proven successful to save more homeless or relocating animals and
reduce the risk of failed adoptions. Completing this application does not guarantee adoption
approval. Please complete this application and return via Email or US mail. Allow us at
least three business days to process this information and contact your references. We will be
contact you during this process concerning any questions we may have. Your patience is greatly
appreciated! (Use additional sheet if needed.)

Today’s Date:

Name, ID#, and Breed(s) of dog you wish to adopt:

Your Full Name:                                               DOB:

Spouse/Roommate’s Name:                                       DOB:

Street Address:

City/State/Zip Code/County:

Home Phone:                                   Cell Phone:

Email Address:

Your Occupation:                              Work #:

Spouse/Other’s Occupation:                                  Work #:

Do you? Own

How long have you resided at your current address?
If less than one year, please give previous address:

If renting, landlord’s Name & Phone #:
If renting, we will need a statement from your landlord giving his/her permission for you to
have at dog at the above address.
Are you planning to move soon?                  If yes, when and where?

Check which best describes the area in you live: Urban/City
Check type of home: Single Family

Does anyone in your home have known allergies?                  If yes, please explain:

Number of children residing in the home:          Ages:
Adults residing in the home:         Relationship:
Are all members of household in agreement to adopting a dog/puppy?
Do all members of the household work? Yes
How many hours will the dog be home alone?

List any pets currently living in your home:
Pet’s   Dog/Cat   Age   Spayed/    Inside/      Where did you acquire this pet?   # of Years
Name    &         Sex   Neutered   Outside/                                       Owned
        Breed                      Both
                        Yes         Inside

                        Yes        Inside

                        Yes        Inside

**If you have any additional pets, please list them below:

List any pets you NO LONGER have:
Pet’s       Dog/Cat        Spayed/    Inside/      When did you     Where is this pet now?
Name        &              Neutered   Outside/     Have this pet?
            Breed                     Both
                           Yes         Inside

                           Yes         Inside

                           Yes         Inside

If you have had additional pets, please list them on a separate sheet using same format.

Name of Current and/or Past Veterinarian(s):

Vet’s Phone #:                        # of Years Known:

Please notify your veterinarian that we will be calling so they will release information.

What type of dog are you looking to adopt: Indoor/house:     Outside:
Gift:    Child’s:      Hunting:     Companion for other dog/cat:    Protection:

Rate the activity level of your home: Quiet:            Busy/Frequent Visitors:
Active family with kids:          Very busy/sometimes hectic:

Is this your first experience with a dog? Yes
If yes, have you researched dog and/or puppy care? Yes
Do you have a fenced in area for the dog/puppy? Yes         Size:
If no, which of the following do you plan to use? Electronic Fencing:       Tie Out:
Cable Runner:        Chain/Dog House:           Garage:       Outside Kennel:
Run Free:
Do you know how to crate train a puppy/dog? Yes
Do you know how to housebreak a puppy?           Yes
When you are home, where will the dog be kept? (i.e. kitchen, living room, bedroom,
laundry room, basement)
Where will the dog/puppy sleep at night?
When no one is home (i.e. work, shopping), where will the dog be kept (be specific)

What arrangements have you made for the dog while you are away or on vacation?

Are you familiar with canine heartworm disease and preventative? Yes
Are you familiar with Animal Control ordinances and required licensing in your area? Yes
Have you ever taken a dog to obedience classes?                      Yes        No
Are you planning on taking this dog/puppy?                           Yes        No
Do you understand the financial cost of owning a dog?                Yes        No
Are you taking this dog/puppy for a vet visit
       within one month of the adoption?                             Yes        No
Are you familiar with introducing your new dog to
       the children & current pets residing in your home?            Yes        No

(Dogs may experience stress or confusion in their new environment, please be patient and
give the dog time to adjust.)
Would you agree to a “home visit” by a volunteer to your home prior to and/or after
adoption (by appointment only)?          Yes           No

Puppy Adopters – you will be legally obligated to have the puppy spayed/neutered by the
age of 6 months and provide us with a copy of the spay/neuter certificate for our files. Are
you willing to comply?          Yes        No
 References: Please list at least three references that are familiar with your family and
lifestyle (only one relative please).

Name:                                     Relationship:

Address:                                 City/State/Zip:

Phone #:                                 Cell #:

Name:                                              Relationship:
Address:                                       City/State/Zip:
Phone #:                                       Cell #:

Name:                                              Relationship:
Address:                                       City/State/Zip:
Phone #:                                       Cell #:

Please take a moment to review your application. Missing or unclear information may
delay or prevent approval. Please read the following page carefully as this is your contract
you will sign upon adopting a dog.
I have read the above information carefully and have filled out this application to the best of my knowledge. I
understand that omission of information and/or failure to answer all questions honestly can result in this application
being declined. I give “Rescue Me” and its associates’ permission to fully investigate the information provided, as
well as contact veterinarians and related persons and officials. In addition, I understand the adoption decision is
dependent on many factors, including but not limited to, the compatibility of the family and home to the individual
animal, and other applications received on this animal.

By signing this contract, I attest and swear that all information is accurate and true to the best of my
knowledge and that I have never been charged or convicted of animal abuse, neglect or maltreatment.

All dog adoption contracts approved by Rescue Me–Purebred K9 Rescue, Inc., are subject to the following
terms and conditions:
1. The Adopter (herein known as the individual adopting the said name dog) agrees that the dog will be kept only as
a domesticated house pet. This means that the dog will be kept indoors, as a part of the family, except for periods of
exercise in a fenced-in area or on a leash.
2. The Adopter agrees to adhere to all local licensing requirements for the dog. The Adopter will be given proof of
spaying/neutering and rabies vaccination in order to obtain the licensing. The license must be obtained and a copy
presented to Rescue Me.
3. In the case of adopting a puppy and the puppy has not been spayed/neutered, the Adopter agrees to have said
puppy spayed/neutered by seven months of age and to provide Rescue Me with such documentation that the
procedure has been completed by their veterinarian. Further, licensing of the puppy must be obtain according to
local licensing requirements (usually one year of age). Proof of licensing should be sent to Rescue Me.
4. The Adopter grants Rescue Me the right to make periodic scheduled visits to the Adopter’s premises for the
purpose of checking on the general health and welfare of the dog and to assure that spaying/ neutering/licensing has
been adhered to according to the terms and condition of this agreement.
5. The Adopter herein states that he/she is 19 years of age or older and that all family members are in agreement
with this adoption, and to their knowledge, no one in the home is allergic to dogs.
6. The Adopter represents that he/she has never owned an animal which has been confiscated by the Animal Control
Officer or Humane Society in violation of state or local animal control regulations or animal adoption contracts.
7. If the Adopter is leasing an apartment, he/she agrees to provide written permission, along with a phone number of
the landlord, allowing the dog to reside in the apartment.
8. If for any reason the Adopter is unable to provide care for the dog, the Adopter agrees to return said dog to
Rescue Me. The Adopter shall not offer the dog for sale or give the dog to any third party without prior written
consent of Rescue Me.
9. The Adopter agrees that Rescue Me shall have the right to immediate possession of the dog if, in the judgment of
Rescue Me, the dog is receiving inadequate care, being improperly housed or handled, or has not been spayed or
neuter on or around the date agreed as of the signing of this contract.
10. The Adopter agrees to pay Rescue Me the sum of $300.00 as liquidated damages in the event the terms of this
contract are breached. This liquidation of damages does not bar Rescue Me from seeking return of the dog by
judicial process and/or other legal means if necessary.
11. The Adopter hereby declares that they have been made aware that a dog’s behavior/personality may change after
it leaves Rescue Me and accustoms itself to their new home and environment. And, further, Rescue Me makes no
representations or warranties as to the temperament, health, or mental disposition of any dog put up for adoption.
12. The Adopter fully understands and agrees that there will be NO REFUND OF THE ADOPTION FEE should the
adoption not be successful. We make every effort to place our dogs in permanent homes whereby they will not be
returned, as this can cause undo stress on the dog.
13. The Adopter hereby accepts possession of, title to (subject to the conditions of the adoption contract) and
responsibility for said dog adopted and agrees to release and discharge Rescue Me forever from liability for any
injury or damages to any person or property caused by the adopted dog, and from any causes of action, claims, suits,
including legal fees or demands whatsoever that may arise as a result of such injury or damages.
14. THE UNDERSIGNED understands that the parties hereby released and admit no liability of any kind by reason
of the said adoption and that said adoption fee is made to terminate any further controversy respecting any and all
claims for damages that said Adopter(s) has heretofore, asserted or might personally or through personal
representatives hereafter assert because of said adoption.
15. By placing my signature below, I release Rescue Me-Purebred K9 Rescue, Inc. of any and all liability issues
concerning this dog. From this day forward. I have been informed of any and all behavioral issues known by the
rescue including, but not limited to, previous bite history. The rescue has also informed me of all known health
issues concerning this dog, past and present, and from this day forward is released from any and all liability. Please
initial: ________

      (This will be dated and signed on the date of adoption, not when completing the

I have read and received a copy of and, hereby, agree to abide by ALL THE TERMS AND

CONDITIONS set for in this adoption application on the _____day of ___________, 20___.

Signature of Adopter(s):   ______________________________________________________

Signature of Rescue Me Representative: __________________________________________

Date: ______________________________________

PET Name & ID ____________________________                    Adoption Fee: $ _________

Further Terms and Conditions:__________________________________________________

If Mailing Application Send to:           Donna Foley
                                          PO Box 758
                                          Oneida, NY 13421


Rev (9/22/12)

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