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Animal #         *Animal Name:

Microchip #:

Please complete all information below:

*First Name:            

*Last Name:            

*Street Address:      

*City:                        *State:    *Zip:

Home Phone:                 Work Phone:

Cell Phone 1:                 Cell Phone 2:

Driver’s License #:   

Birth Date:              

*Email Address:      

Veterinarian's Name: Clinic's Name: Phone#:

Street Address: City: State: Zip:

Your Family and Home

Type of Dwelling:  -Select- House Duplex Apartment Mobile Home TownHome Condo

Do You? -Select- Own Rent   (Written approval from landlord required if renting)

If renting, Landlord’s Name:

Landlord’s Phone #:

Does your living situation have animal restrictions? -Select- Yes No
(e.g. breed, size, # of animals, etc.)

Do you belong to a neighborhood or mobile home association?  -Select- Yes No
(Written approval from association required)

How many people are living in the home? Adults  Children

Please list the ages of any children: 
What other animals do you have in the home? 

Does anyone in the home have allergies to animals? -Select- Yes No

If yes, please explain: 

Do you have a fenced in yard? -Select- Yes No Not Yet

If yes, what type of fencing is it? -Select- Chain Link Privacy Invisible Other

If yes, how high is the fencing?  -Select- 4ft 6ft 8ft 10ft Other

If yes, is it fenced on all sides and secured? 

If no, how will the dog be contained when outside? 

Will the dog ever be left outside alone? -Select- Yes No

If yes, for how long? 

Ownership Responsibilities

Have you ever had a pet before? -Select- Yes No

If yes, please list:
 1) Name:    Type of pet/breed:
      Dates the pet lived with you:
      What happened to the pet? -Select- Still Have Surrendered Given Away Deceased Ran Away
      If anything other than “Still Have,” please elaborate:

2) Name:    Type of pet/breed:
      Dates the pet lived with you:
      What happened to the pet? -Select- Surrendered Given Away Deceased Ran Away Still Have
      If anything other than “Still Have,” please elaborate:

3) Name:    Type of pet/breed:
      Dates the pet lived with you:
      What happened to the pet? -Select- Surrendered Given Away Deceased Ran Away Still Have
      If anything other than “Still Have,” please elaborate:

How long have you been looking to add a dog to your family?

What is the primary reason you are getting a dog at this time?

What are you looking for in a dog?

Have you done research on this breed(s)? -Select- Yes No

Where will the dog be allowed in your home?

Where will the dog sleep at night?

Where will the dog be kept when you are not home?

Average number of hours the dog will be left alone each day:

Please describe what your daily routine with the dog will be:

Are you familiar with crate training and its use? Please describe:

Basic Care

Are you willing to assume ALL veterinary costs from the date of this adoption forward? -Select- Yes No

Who will feed the dog?


Type of food/diet:         Meals per day:


Who will exercise the dog, and type of exercise will you participate in?

Who will groom the dog?

Who will train the dog?   

What steps will you take if your pet is missing/runs away?

Behavior Considerations

Have you dealt with the following behaviors in the past?
Please describe how you have handled or would handle each behavior:

Potty training: 

Being mouthy while playing: 

Biting while protecting a toy:

Biting while protecting food: 

Playing too rough with other pets:

Forging ahead when walking on leash:

Not coming when called:

Jumping the fence:

Digging:

Begging for food:

Barking excessively:

Chewing inappropriate items:

Won’t get off the furniture:

Doesn’t like to be groomed:

Fighting with other dogs:

Chasing cats:

Jumping up on you:

Biting a person:

If for any reason you are unable to take care of this dog, it MUST be returned to BWB RESCUE!

We reserve the right to determine whether or not it is in the best interest of the dog to be adopted by any individual, and, if not, to refuse the adoption.

Thank You for taking the time to complete this application. Be assured we will give this our highest priority.
You will be hearing from us soon!