First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone

Alt Email

Date of Birth (Note: You Must Be 25 Years or Older To Adopt A Dog)*

Occupation*

Marital Status*

Spouse/Significant Other's Name*

Spouse/Significant Other's Date of Birth*

Spouse's Occupation*

In what type of home do you live*
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

Do you own or rent your home*
Choose one: Rent Own

Please provide your Landlord's contact information (Name/Phone #)

If you rent, have you received the approval of your landlord to have an animal
Choose one: Yes No

Do you have a fenced yard?*
Choose one: Yes No

What type of fence
Choose all that apply: Privacy Chain Link Invisible

What is the height of the fence*

Is your yard FULLY Fenced?*

If you do not have a fully fenced yard, how do you plan on pottying your dog?*

How many people reside in your household*

Do you have any children in your household OR children that visit you- and if yes, what are their ages?*

If no Children, are you planning on having children? *
Choose one: Yes No

Please list everyone that resides in your home *

Does anyone in your household smoke? *

Does anyone in your household have allergies to animals? *

Please describe all pets currently with you (age, sex, altered status, BREEDS, WEIGHTS. Please note - If you have a current pet or pets, they must be up to date on vaccinations and spayed/neutered. This includes cats. Dogs must have annual vet exams.) *

Please describe pets that are no longer with you (type, sex), and what happened to them. *

Veterinarian's Name and Phone Number*

What name are the vet records under?*

Have you ever given up a pet? If yes, please explain*

Why are you interested in adopting a pet at this time*

Have you applied with any other rescue*
Choose one: Yes No

Which Rescue(s) have you applied to and when?

How did you hear about us*

Does everyone in your household want a dog and know that you are applying for one:
Choose all that apply: Yes No

Are you adopting the dog for yourself? *
Choose one: Yes No

How much time will the animal spend alone during the day*

Will the animal be kept inside or outside*
Choose one: Inside Only Outside Only Inside and Outside

Where will the animal be kept when you are home*

Where will the animal sleep*

Where will the animal be kept when you are not home*

Do you understand that small breed dogs are HIGHLY prone to dental issues and will need dental care throughout its lifetime? *
Choose one: Yes No

Will you keep the dog licensed, and have ID tags (other than a license) on the dog at all times?*
Choose one: Yes No

What traits are you looking for in a pet

Would you consider a special needs dog (age, temperament, medical needs)

Which animal are you interested in
Choose an animal: Harvey Jolie Lexie Libby Lottie Max Ollie Princess

Please list one personal reference (relative), Name, Address, Phone Number: *

Please list two personal references (non-relative), Name, Address, Phone Number: *

By checking YES, you understand that an adoption fee is required for each animal and that it is Non-Refundable. *
Choose one: Yes No

By checking YES, I understand that the adoption fee is NON-REFUNDABLE*
Choose one: Yes No

Will you allow a representative from our rescue to visit your home? *
Choose one: Yes No

Please list any other information/comments you feel may be helpful in placing a dog in your home

By checking YES, you understand that Pixie Mamas Rescue has the right to either deny or approve your application without explanation. A denial is not a rejection of you as a person; it is a refusal to place a pet in a situation that we do not feel is a good match or does not meet our policies. *
Choose one: Yes No

I certify that the information entered on this applicant is true. Enter your name and date*

Please be advised that we are all volunteers dealing with not only volunteering and fostering but with our own personal homes and lives. Therefore it is not always possible to contact every applicant.

By checking this box, you give Pixie Mamas Rescue permission to schedule a home visit with the animal of your interest, and upon doing so, you acknowledge that as the Premises of the Owner or Occupier, our animals, guests, items and activities thereon, could pose dangers to people and other animals. Such dangers include, by way of example and not limitation, animals that can bite, trip, knock down, and fight, persons who cannot control their dogs, and activities involving dogs/cats that can result in injury from bites or other causes. Accordingly on behalf of the PMR representative, the Owner or Occupier or his/her spouse and minor children, and anyone else who is on the Premises of the Owner or Occupier, (a) waives any and all legal duties on the part of PMR and assumes the risk of injuries, losses, damages, costs and expenses by any means above described, and other injuries, losses, damages, costs and expenses of every possible cause and description unless inflicted intentionally or recklessly by the agents and employees of Owner or Occupier.