Name of animal you are interested in

First Name* Last Name* Phone #.*

Street Address * Apt. # City * State * Zip *

Email *

Spouse or Roommate’s name(s)*

Please list the other members of your household and their ages*

Please list name, age and type of current and previous pets you have owned in the past five years (including deceased pets) and list whether or not each animal was spayed/neutered.*

This pet (or pets) was kept?* Inside Outside

Do you still have this pet (or pets)?* Yes No

If you don’t still have this pet (or pets), why not?

Please provide your current Vet information (if none, explain below)

Vet's Name * Vet's Phone * Name on the account*

I live in a *
House Apartment Condo Dorm Mobile Home

Do you rent or own? *
Rent Own

Name of Landlord/Condo/Mobile Home Manager Phone

Please provide two references, including phone numbers where they can be reached.

Reference #1 Name Phone Relationship

Reference #2 Name Phone Relationship

The age of the dog that I prefer is*
Puppy (up to 6 months) Young Adult (6 mos-2 years) Adult Senior No Preference

Household activity level*
Quiet Active Very Active

Outside visitors*
Very Frequently Occasionally Seldom

I prefer a dog that is*
Very Active (most puppies) Somewhat Active Pretty Mellow

I would like a dog that is* (Please check all that apply)
Good with cats Good with dogs Good with kids Doesn't Matter

I would like to adopt this dog/puppy because I want* (Please check all that apply)
Personal Protection To Breed For Children Farm Dog Companionship Hunting Dog A gift for

Your experience with dogs*
First time owner Have had 1 or 2 Knowledgeable/experienced

Are you familiar with the breed you have chosen?*
Yes No

Gender preference*
Male Female Doesn't matter

I prefer a dog that is*
Already spayed/neutered I will spay or neuter the dog I do not plan to spay or neuter

If not planning to spay/neuter please explain why

Please describe the size dog you are looking for*
Toy Small Medium Large Giant Doesn't Matter

Please describe the coat length you are looking for in a dog*
Short Medium Long Non-Shedding Doesn't Matter

Which member of your household will hold primary responsibility for your pet for the following?

Feeding * Training *

General Care * Taking to vet *

Have the children in the household interacted/lived with dogs/puppies?*
Yes No

Do you have food, shelter, a crate and/or other items ready for this dog?* Please explain:

It is estimated that it will cost $ 500 per year, (not including medical emergencies) to support a pet. Is this an expense you can afford?*
Yes No

How much time per day do you plan to exercise this dog?*

Where will you exercise your dog?*

Do you walk your dogs?*
Daily Couple of times a week Not much / plays in yard

Do you plan to take your dog to obedience classes?*
Yes No Not Sure

Are you aware of the license, leash, and animal laws of your community?*
Yes No

It may take your new dog a month or longer to adjust to its new home. Are you prepared to allow this much time?*
Yes No

Do you have any concerns about this?

Do you have a fenced-in yard?* Yes No

If fenced, please describe the height and type

How do you plan to housebreak your dog/puppy?*

Who will care for your pets if you are on vacation or gone for a longer period than normal?*

Dogs often live more than 15 years. Are you ready to be responsible for the pet’s entire life?*
Yes No

What type of food do you intend to feed your dog and how often?*

How long are you and the other members of your household gone during the day?*

How long will dog be home alone daily?*

When not home, this pet will be*
Crated Confined to 1 room of the house Have run of house Kept outside - Other

Where will the dog be kept?*
Inside Outside (all of the time) Outside (sometimes)

Please explain

If outside, how will the dog be sheltered?*
Not Applicable Fenced Yard Barn Garage Kennel Dog House Running Cable - Other

Will you allow a home visit to be done by a rescue representative prior to adoption?*
Yes No

By submitting this application, you certify that all of the above information is true and correct and that you are over 18 years old. Animal Lifeline is hereby given authority to use this information to process your application. You understand this application is the property of Animal Lifeline. Furthermore, you understand that Animal Lifeline assumes no liability for the temperament or health of any dog placed in your home, nor do they assume any liability for damages caused by the dog or responsibility for any expenses arising from such damages. You agree to indemnify and hold Animal Lifeline harmless from and against all of the above.

This application is the property of Animal Lifeline | 94 Elfman Drive | Doylestown, PA 18901

When you have completed your application, click the SUBMIT button below and the data will be saved and transmitted to Animal Lifeline. If you leave this page before clicking SUBMIT, your data will be lost!

Thank you for your interest in adopting a dog through Animal Lifeline. One of our volunteers will contact you within the next several days.