Blue Eyes Rescue, Inc.

Adoption Application
What is the name of the pet(s) you are interested in? _______________________________
How did you hear about us? _______________________________________________________
Personal Information
First and Last Name_______________________________________________________________
Email address ____________________________________________________________________
Home Address____________________________________________________________________
Phone number ___________________________________________________________________
Number of children and ages _____________________________________________________
Employer Name __________________________________________________________________
Work Phone Number _____________________________________________________________
Co-Adopter Name ________________________________________________________________
Co-Adopter email ________________________________________________________________
Co-Adopter Employer ____________________________________________________________
Co-Adopter Phone Number________________________________________________________
How long will newly adopted pet be left alone each day? ____________________________

Do you live in a home, apartment, townhome? ______________________________________

Do you own or rent? ______________________________________________________________
If renting, when does your lease expire? ____________________________________________
Is there a chance you might move in the next 2 years? ______________________________
Are you aware of any restrictions on having pets in your home? ______________________
If so, what are they? ________________________________________________________________
Does your home have a yard? _______________________________________________________
Where will new pet be kept most of the time (outside, garage, inside, etc.)?
____________________________________________________________________________________
Do you own a crate? ________________________________________________________________
In the event that you can no longer offer care, do you have an alternate caregiver?
_____________________________________________________________________________________
If so, what is the relationship, name, and phone number?
_____________________________________________________________________________________
Do you understand that the dog will take time to adjust to its new surroundings and
that certain behavior issues might occur? ____________________________________________
We will attempt to be honest with our evaluation of temperament of any dog in our
rescue. Do you understand and accept that often a complete history of an adopted pet
may not be know and you might encounter certain behavior problems? _______________
Are you prepared to work with your newly adopted pet with patience until the dog
stabilizes in the environment? _______________________________________________________
Your reaction if the newly adopted pet urinates/defecates inside the house?
_____________________________________________________________________________________
Your reaction is the dog sheds? _____________________________________________________

Your reaction if the dog scratches or play bites? _____________________________________

Your reaction if the dog begins to bark or howl? _____________________________________
Your reaction if the dog chews or scratches furniture? _______________________________

Other Pet information-List any current pets you have including breed, age,
temperament, date altered
_____________________________________________________________________________________
_____________________________________________________________________________________
Current Veterinarian or vet you will use:
_____________________________________________________________________________________
Name ______________________________________________________________________________
Address ____________________________________________________________________________
Phone number ______________________________________________________________________
The submission of this application authorizes your veterinarian to cooperate with and
disclose in full any and all requested by Blue Eyes Rescue.
If you previously owned dogs and do not know please explain why they are no longer
with you
_____________________________________________________________________________________
_____________________________________________________________________________________
Please list three references and their phone numbers
1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________

Applicant signature____________________________________________

By signing above I certify that the information provided on this form is true and
correct and understand that, prior to being approved for adoption, this information
will be verified. A home visit might need to be scheduled and if so, all members of the
household will need to be present. If upon visit, we find that the information provided
in this application proves to be false, we retain the right to deny your application or
remove the animal from your premises without a refund of any monies paid. I certify
that I am physically and financially able to care for this animal and I understand the
proper food and veterinarian care can be costly and I am able and willing to meet these
requirements. Approved adoptions require a signed Adoption Contract.

blueeyesrescue@gmail.com