Charlie's Wish Animal Rescue

Adoption Application

Date Time *

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The name of the dog you are interested in:
Name *
Email *
Phone number *

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Address *
Street Address *
Address Line 2
City *
State / Province / Region *
Postal / Zip Code *
Country *
Age range and gender of adults in household: *
Age and gender of children in the household (anyone under 18 years old): *
Will the dog reside in your home? *
 Yes 
 No 
Do you live in a House, Apartment, Trailer, Other? *
 House 
 Apartment 
 Trailer 
 Other 
Do you own or rent your home? *
 Own 
 Rent 
If you rent, do you have landlord's permission to keep a dog?
 Yes 
 No 
Contact information of your landlord. (Name and phone number)
How long have you lived at this address? Year & Month *
Do you plan on moving in the next few years? *
 Yes 
 No 
What will happen to your pet if you move? *
Who will take care of the dog when you are on vacation or out of town? *
Do you have a completely fenced yard suitable for a dog? *
 Yes 
 No 
If Yes, describe the type of fence. (Type and height)
If no fence, how will you handle exercise and toilet needs?
How many hours a day must the dog be alone? *
 Less than 4 hours 
 4-8 hours 
 more than 8 hours 
Where will the dog be if left alone? *
Who will be the primary care giver for the dog? *
Do you intend to keep this dog primarily inside or outside? *
Where will the dog sleep? *
Please list the dogs and other animals currently in your home (age, sex, breed, temperament, socialization with dogs). This question must be answered in full
Are the animals currently in your home neutered or spayed?
 Yes 
 No 
If No, explain why.
Are the animals in your home current on vaccinations, heartworm prevention, flea prevention and rabies?
 Yes 
 No 
If No, explain why.
How many dogs have you owned in the past five years that are currently not in your home? What happened to them?
Do you realize that a dog can cost in the upwards of $600 a year between regular vet visits and food. This amount does not include emergency trips to the vet office for those unexpected situations. Are you able and willing to take on that financial responsibility? *
 Yes 
 No 
Do you have a regular veterinarian?
 Yes 
 No 
Contact information of your vet. (Name and phone number)
Please keep in mind that you are applying for a lifetime companion. Are you willing to make the investment in both time and money to care for and properly manage your new pet (this includes house training, obedience training, food, toys, methods of restraint, yearly license, yearly shots and visits to the vet, possible obedience classes, etc.) *
 Yes 
 No 
Are you willing to keep your animal of flea/tick/heartworm preventative (heartworm treatment is a very long, painful and expensive treatment)? *
 Yes 
 No 
Would you be willing to consider a different dog if we feel this one is not a fit for you and your family? *
 Yes 
 No 
First Personal References (someone not living in your home):Provide their name, the relationship with you, and phone number. *
Second Personal References (someone not living in your home):Provide their name, the relationship with you, and phone number. *
I agree that all of the information I have given in this adoption form is true and complete. Please initial *
I agree that this dog will reside in my home. Please initial *
After adoption I agree to provide Charlie’s Wish Animal Rescue with address, e-mail and phone number changes I will provide the dog with adequate food, water, shelter, training, affection and medical care and the dog will not be tied out or on a run. Please initial *
I understand that the Charlie’s Wish Animal Rescue is not responsible for the accuracy of information received about the temperament, habits or physical condition of the dogs available for adoption. However, all information provided is given in an effort to do the best in knowing a dog prior to adoption. Please initial *

Out of Harm's Way -- One Dog at a Time!