Adopt A Bully

Interested in Adopting *

Clark Kodak

* Indicates required field

Adopters Name *

First

Last

Phone Number *

Adopters Name *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

List all family members living in your home INCLUDING YOURSELF (Name/Age/Relationship) MUST INCLUDE AGES!!!!!!!! *

Is anyone living in your home allergic to dogs? *

Yes No

If yes, who *

If renting what name is the lease under? (If this doesn't apply use N/A) *

Do you *

Own (WILL VERIFY WITH COUNTY) Rent (WILL VERIFY WITH LANDLORD)

Landlords Name (If doesn't apply use N/A) *

First

Last

Landlords Phone Number *

Do you have a fenced in yard? *

Yes No

Yard Size *

Type of fencing (chainlink, privacy, ect) *

How tall is your fencing? *

If no fence how will you exercise the dog? *

Do you lock/secure your gate/gates? *

You secure your gate/gates with what? *

Do you have a pool? *

Yes No

Does your meter reader have to enter your yard? *

Yes No

Does your home have a dog door? *

Yes No

List all your PAST animal history (Name/Age/Breed/Spayed or Neutered/Reason they are no longer with you) *

List all of your CURRENT pets (Name/Age/Breed/Spayed or Neutered) *

Tell us a little about your life style so that we can pair you with the right dog. (Do you jog, have a lot of social activities at your home, couch potatoes, etc.) *

Do you have a current vet? *

Yes No

Vet Clinic Name *

Vet Phone Number *

Please list all previous Vet Clinics and phone numbers so that we may obtain current and previous vet records *

Under what circumstances would you chain up a dog? *

Under what circumstances would you give up a dog? *

Why did you choose this breed? *

Your interested in adopting *

Male Female

Interested in adopting *

Baby Young Adult Senior

Color of dog *

Purpose of Dog *

Where will the dog sleep in bad weather? *

When you go to work where will the dog stay? *

How much time will the dog be home alone on a daily basis? *

I am adopting this dog for? *

What kind of behavior do you find unacceptable? *

If the dog has behavior problems how will you discipline him/her? *

Do you understand that a home check where the dog will be living is required before the adoption will be approved? *

Yes No

Are you opposed to a home visit after the adoption process is complete to verify the dog is adjusting well to your home? *

Yes No

I understand and agree that by signing below that I fully release NWA Bully Haven Rescue from any and all liability accidents caused by the adopted dog while the adopted dog is in your home and care. This includes any pets, children, friends or guests. BY SIGNING BELOW I UNDERSTAND AND CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE. *

Date *

Indoor or Outdoor Dog *

Indoor Outdoor

Adopt A Bully

ADOPTION APPLICATION