First Name*
Last Name*
Address
City
State/Province
Zip/Postal Code -
Email*
Home Phone
Work Phone x
Cell Phone
Alt Email
Text/Pager Email
Your Name:*
Name of your Spouse / Partner:*
Home Phone:*
Alternate Phone:*
Email Address:*
Address:*
Which animal are you interested in (select name in box)?* Choose an animal: Coco Francine Halena Kessler LisaLisa
Occupation:*
Employer:*
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? If you rent, describe the setting, e.g., house, apt building, condo.* Choose one: Rent Own
How many adults in the home and relationship to the applicant (s)?*
Please list children in home and ages. If none please enter None in the box.*
Tell us a little about the pets you currently have in your household....type, breed, age, sex, spay/neuter, temperment, etc. If no other animals, please enter None*
Please briefly tell us what animals you have had in the past five years (not including current ones) with a brief description*
Please list your current vet's name, address, & phone number:*
Briefly tell us why you are interested in this animal?*
List two personal references, including phone numbers and emails (preferably not family members)*
What is your age preference?
Do you have a fenced yard?* Choose one: Yes No
Are you familiar with crate training?* Choose one: Yes No
Where will the animal spend most of each day?*
Where will the animal sleep at night?*
How much time will the animal spend alone during the day?*
How did you hear about ROSA's Rescue?*
Additional comments or information that you would like to include*
By entering my name below, I acknowledge that I completely read this questionnaire and comprehend it fully. I am aware that applying does not ensure approval and that untruthful answers or failure to comply with the requirements of this application or the adoption contract can result in the forfeiture of any rescue dog adopted by me.*