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					MONSIEUR PIT BULL RESCUE, INC. EIN: 20-4610650
BULLY BREEDS ADOPTION APPLICATION

Monsieur Pit Bull Rescue, Inc. (M.P.B.R.) P.O.BOX 363938 N. Las Vegas Nevada 89036 Phone: 702-632-8981 • Cell: 702-806-3822 E-mail: monsieurpitbullrescue@hotmail.com Website: www.monsieurpitbowtique.com Petfinder website: www.petfinder.com/shelters/NV102

Bully Breeds Adoption Application
(All applications MUST be filled out completely)

Thank you for your interest in adopting one of our dogs. We have a rigorous screening process for potential adopters. We only match our dogs with responsible owners who will provide homes for life. In order to be considered for an adoption you must: 1) be 21 years of age 2) have the knowledge and consent of all adults living in your household 3) have a valid ID with current address 4) understand that completing this application does not guarantee adoption and that MPBR must approve your application.

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MONSIEUR PIT BULL RESCUE, INC. EIN: 20-4610650
BULLY BREEDS ADOPTION APPLICATION

* We require all of our dogs are spayed or neutered. * Meet with one of our breed advocates in person. * Must own or have landlord approval. We will verify. * Must have either a fenced in yard or proof of safe exercise area. * Agree to a home visit before adoption and for follow up visits. * Must demonstrate an understanding of the challenges of bully breed ownership

Applicant First Name __________________________ Last Name ______________________________ DOB ________ Employer: ____________________________________________________ Occupation: ________________________________________________________________ How long have you worked for this company? ________ E-mail address: _______________________ Driver's License #:_______________________

Co-applicant (Spouse or Significant Other) First Name ________________ Last Name ________________________________________

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MONSIEUR PIT BULL RESCUE, INC. EIN: 20-4610650
BULLY BREEDS ADOPTION APPLICATION

DOB ________ Occupation ____________________________________________________ Address: _______________________________________________ Apt. /Suite #:_________ City: ________________________ State: ___________________ Zip: __________________ Home and cell phone: _______________________/__________________________________ Work phone: _________________________________________________________________ E-mail address: _______________________ Driver's License #:________________________ List all other people in your household: Name _______________________________Age____________ Name _______________________________Age____________ Name _______________________________Age____________ Name _______________________________Age____________ Name _______________________________Age____________ Name _______________________________Age____________ Is anyone allergic to dogs? [ ] Yes [ ] No [ ] No

Do all family members want to adopt a dog? [ ] Yes

How far could you drive to pick up a dog? __________________ If needed, would you pay for or assist with shipping expenses? [ ] Yes Do you [ ] other [ ] rent [ ] No

[ ] own [ ] live in an apartment [ ] house [ ] condo

arrangements__________________________________________________________________

Name of apartment complex/landlord: _______________________________________________________ Contact phone: _______________________________ Does your municipality have breed specific restrictions? [ ] Yes [ ] No [ ] Don’t know

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MONSIEUR PIT BULL RESCUE, INC. EIN: 20-4610650
BULLY BREEDS ADOPTION APPLICATION

If so, please describe the nature of the restrictions: _____________________________________________ ______________________________________________________________________________________
IMPORTANT: Many homeowner's insurance companies have breed blacklists which include, but are not limited to, pit bulls, American Pit Bull Terriers, American Staffordshire Terriers, Staffordshire Bull Terriers, Rottweilers, Dobermans, Akitas, American Bulldogs, Chows and wolf-hybrids and will not insure you if they reside in your home or may cancel your insurance if you add a dog of these breeds to your home. Please check your homeowner's insurance policy regarding breed discrimination BEFORE adopting a pit bull type dog. Landlords may also have these same breed restrictions due to their insurance policies.

Why are you interested in adopting a Pit Bull or American Staffordshire Terrier? ____________________________________________________________________________________ Have you ever personally owned a Pit Bull or American Staffordshire Terrier? [ ] Yes: How many? _____What years did you own them? ____________________________________ Did you breed puppies? [ ] Yes [ ] No

Why are the dog(s) no longer with you? _____________________________________________ [ ] No: What experience do you have with this breed? ________________________________________ Have you ever owned a cat or dog before? [ ] Yes [ ] No If so, were they spayed/neutered? [ ] Yes If not: Have you ever been responsible for taking care of someone else's dog? [ ] Yes [ ] No [ ] No

How many dogs have you owned in the past? _______ if any, please check what happened to each of them: euthanized, run over, died of old age, sold, given away, ran away, medical condition. How many pets do you have now (including roommates' pets)? _____Dogs _____Cats _____Rabbits _____Birds _____Ferrets______ Other: _____________________________________________________

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MONSIEUR PIT BULL RESCUE, INC. EIN: 20-4610650
BULLY BREEDS ADOPTION APPLICATION

Any other livestock (sheep, goats, horses, chickens...)? [ ] On my property [ ] Nearby [ ] No livestock Breed: ________________ Altered? [ ] Yes [ ] No Breed: ________________ Altered? [ ] Yes [ ] No Breed: ________________ Altered? [ ] Yes [ ] No Do your animals wear identification? [ ] Yes [ ] No If so, what type (i.e. tag, microchip)? ___________________ If not, why? ___________ _______________________________________________________________________ Veterinarian's name: ________________________________Phone:_________________ Location of veterinarian: [ ] Inside / [ ] Outside / [ ] Both [ ] Inside / [ ] Outside / [ ] Both [ ] Inside / [ ] Outside / [ ] Both

Do you have any children living with you? [ ] Yes [ ] No Number of children in the household: ________Ages of children: ___________________ Do children visit your house often? [ ] Yes [ ] No Will any of these children who live with you or visit help care for this dog? [ ] Yes [ ] No When home alone, where will the dog spend its time?

Indoors:
[ ] Loose in home [ ] Loose in basement [ ] Crate

Outdoors:
[ ] Garage/carport [ ] Loose in fenced yard [ ] Loose in kennel run

[ ] Tied up outside: [ ] Cable Run

[ ] With a chain

Other (Describe):________________________________________________________________________

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MONSIEUR PIT BULL RESCUE, INC. EIN: 20-4610650
BULLY BREEDS ADOPTION APPLICATION

Where will the dog sleep at night?

Indoors:
[ ] Loose in home [ ] Loose in basement [ ] Crate

Outdoors:
[ ] Garage/carport [ ] Loose in fenced yard [ ] Loose in kennel run [ ] Tied up outside

Other (Describe):________________________________________________________________________ How will you exercise the dog? (Check all that apply) [ ] Leash walks every day [ ] Will have cable or dog run in the yard [ ] Will be free to run in fenced yard [ ] Will have supervised access to unfenced yard [ ] Will be free to roam around (Off leash and unsupervised in unfenced area) [ ] Will bring to dog park (Public area where dogs can run and play together off-leash) [ ] Other - please specify: _________________________________________________________________ [ ] I am interested in a specific dog I saw online (name, ID#) ____________________________________ *Note: Final adoptions are based on in-depth evaluations to match each dog with the most appropriate household. As a result, we can not guarantee that you will adopt this dog.

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MONSIEUR PIT BULL RESCUE, INC. EIN: 20-4610650
BULLY BREEDS ADOPTION APPLICATION

[ ] I am interested in meeting various dogs Please indicate your preferences: [ ] Male [ ] Female [ ] No preference [ ] Puppy-2 years [ ] 2-4 years [ ] Over 4 years okay [ ] Pit bull Terrier [ ] Bull Terrier [ ] Bull Dog [ ] American Staff. Terrier [ ] Staffordshire bull terrier [ ] Mixed breed okay

Other_______________________________________________________________________________ List all plans for this dog: [ ] Pet [ ] Guard [ ] Assistance [ ] Agility [ ] Therapy [ ] Therapy [ ] Obedience [ ] Company for other dog(s)/ pet(s) [ ] Other (describe):_____________

_____________________________________________________________________________________ How many hours will this dog be without people on a daily basis? _____________ Hours Where will this dog stay when you are out of town? ____________________________________________ Are you planning on moving in the near future? [ ] Yes [ ] No

If so, what would you do with your new dog? ___________________________________ How many times have you moved in the past 5 years? _______ Would you ever consider moving somewhere that doesn't allow pets? [ ] Yes [ ] No Do you foresee any major changes in your life in the next 15 years (average life span of a cat) such as marriage, childbirth, health problems due to age, going away to college? [ ] Yes [ ] No If yes, please explain ________________________________________________________________ Do you or anyone in your household currently have any serious health problems? [ ] Yes [ ] No If yes, please describe ________________________________________________________________ Can you provide a permanent home for this dog for 10-15 years? [ ] Yes [ ] No

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MONSIEUR PIT BULL RESCUE, INC. EIN: 20-4610650
BULLY BREEDS ADOPTION APPLICATION

Have you adopted from this rescue or any other shelter? [ ] Yes [ ] No Name & location of shelter? ________________________________________________ Will you provide a good quality of food__________ Raw food? ___________________ How much time are you prepared to allow for your new pet to adjust to your home? _____ ________________________________________________________________________ Are you able to afford a bill of $200-$500 (or more) for emergency veterinary care? [ ] Yes How much do you expect to spend on maintenance for your pet in a year? _____________ Have your ever given an animal away or relinquished an animal to a shelter? [ ] Yes [ ] No [ ] No

If so, why? ______________________________________________________________ Has a dog died on your premises in the last 6 months of distemper, PARVO, or unknown causes? [ ] Yes [ ] No What circumstances, in your mind, justify giving a dog up: moving, new baby, divorce, not getting along with other pets, destroying furniture, behavioral problems, children lost interest, too time consuming, shedding, allergies, housebreaking problems, medical problems, aggressive, other__________________ ___________________________________________________________________________________ If you are unable to keep a dog adopted from MPBR, will you agree to return the dog to us? Will you return the dog to us? [ ] Yes [ ] No Please provide the names and telephone numbers of three references: (your veterinarian can be used as a reference) Name: _______________________ Tel______________________ How long know? ________________ Relationship to applicant: _________________________________ Name: _______________________ Tel______________________ How long know? ________________ Relationship to applicant: _________________________________ Name: _______________________ Tel______________________ How long know? ________________ Relationship to applicant: _________________________________

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MONSIEUR PIT BULL RESCUE, INC. EIN: 20-4610650
BULLY BREEDS ADOPTION APPLICATION

Homeowner’s/Renter’s Insurance Company: _________________ Tel____________________________

Terms of Adoption
The following agreement specifies what we feel is required to provide a safe and loving home for a dog. Please understand that the details of the contract reflect our concern that both owner and dog have a happy life together. The conditions set forth are based on years of experience and a continuing commitment to see that our rescue dogs find safe and happy permanent homes. We hope that you will understand that considerable emotional involvement, time and energy go into insuring that our rescue dogs have the best possible second chance at life. If I am successful in the adoption of a dog through Monsieur Pit Bull Rescue, I herein promise and agree to the following conditions: 1.)____ To allow Monsieur Pit Bull Rescue to contact my references, my mortgage company or landlord, my homeowner’s insurance company, and my veterinarian, to confirm that I am able to adopt a dog of this breed. 2.)____ To allow Monsieur Pit Bull Rescue to do their very best to match my situation and requirements with an appropriate dog, but to hold them harmless and free of liability if such a match is not possible. 3.) ____ To pay a minimum adoption fee of $175 if I choose to adopt a dog through Monsieur Pit Bull Rescue, to help the organization continue their rescue, adoption and education efforts for and about this breed. I understand this fee covers spay/neuter, microchip, starter puppy shots, & worming. 4.)____ To keep any dog that I adopt from Monsieur Pit Bull Rescue in my personal possession, as my household pet and companion, and to provide it with proper and sufficient food, water, shelter, grooming, vaccinations, medical attention, and humane treatment at all times. 5.)____ To ensure the safety of this dog and all humans and animals that come in contact with this dog; that when outside and unattended, the dog is in a secure, fenced yard or kennel run with adequate shelter from the elements; that the dog is always on a leash, or contained within a fenced yard, kennel run, or my home; that the dog is never allowed to come in contact with other humans and animals without adult supervision; that the dog is never chained or tied without constant adult supervision. 6.) ____ To spay or neuter the dog, if not already done, within thirty (30) days of my adoption from Monsieur Pit Bull Rescue, and to provide written proof of said surgery to Monsieur Pit Bull Rescue within ten (10) days of the operation. I will not allow this dog to breed or be bred under any circumstances. 7.) ____ To provide the dog with an ID tag secured to its collar, and to microchip the dog, if not already done. 8.) ____ To obey any and all animal control regulations governing the area in which I live, and to license the dog according to such regulations within one (1) month of adoption. To never transport this dog in the open bed of a pickup truck or similar vehicle without being properly secured.

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MONSIEUR PIT BULL RESCUE, INC. EIN: 20-4610650
BULLY BREEDS ADOPTION APPLICATION

9.) ____ To invest in dog obedience and training courses for the temperament and well being of this dog and my family. 10.) ___ To contact Monsieur Pit Bull Rescue, Inc if this dog becomes lost from my home for more than 12 hours. 11.) ___ To assume full responsibility for this dog’s actions, including any and all damages done by this dog. 12.) ___ Not to sell, trade, transfer ownership, abandon, or dispose of this dog in any way, nor release the dog to any family member or friend, but rather if for any reason I am unable to keep this dog at any point in the future, to contact Monsieur Pit Bull Rescue to assist me in finding a new, appropriate home for this dog. 13.) ___ To allow Monsieur Pit Bull Rescue to examine the dog and its living conditions at any point in the future, and to surrender the dog to Monsieur Pit Bull Rescue if the conditions are found unsatisfactory. No adopter will be considered without prior consent to the "Terms of Adoption". We suggest you make a copy for your own records By signing below, I am attesting to the truthfulness of my answers. Falsification of any of the above information will be grounds for rejection of this application and possible removal of adopted dog from my home. I understand that Monsieur Pit Bull Rescue reserves the right to refuse any applicant. I understand that Monsieur Pit Bull Rescue does their best to verify information about any given dog, but is not responsible for the accuracy of information received or conveyed about temperament, habits or physical condition of dogs available for adoption. Likewise, I understand that it is my responsibility to see and evaluate the dog for myself before agreeing to adopt it. Monsieur Pit Bull Rescue is no way liable or responsible for any damage, accident or injury resulting from the placement of a dog into my household. I understand that if I adopt a dog through Monsieur Pit Bull Rescue, Inc. I will be joining a family of breed advocates dedicated to responsible ownership.

Signed: _______________________________________________Date:________________

Monsieur Pit Bull Rescue, Inc. (M.P.B.R.)

P.O.BOX 363938 N. Las Vegas Nevada 89036 Phone: 702-632-8981 • Cell: 702-806-3822 E-mail: monsieurpitbullrescue@hotmail.com Website: www.monsieurpitbowtique.com

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MONSIEUR PIT BULL RESCUE, INC. EIN: 20-4610650
BULLY BREEDS ADOPTION APPLICATION

FOR OFFICIAL USE ONLY Interviewed by: Date: Comments:

Application:

[_] Approved

[_] Declined

Foster Signature: Date: Reason for decline: Required for all applications Dog Coordinator Signature: Date:

MPBR Bully Breed Adoption Application 11


				
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