Adopter Information Form

Canine Pet Rescue Corp. 2625 Jones Phillips Road

Dacula, GA 30019

Thank you.. for your interest in sharing your life with a dog. We believe that every dog deserves a safe, loving forever home, so we hope that you will understand the time and care we take in matching our dogs with just the right family. The responses on the Adopter Information Form and the Dog Adopter Survey provide us with the framework for placing a dog. Please respond truthfully, supplying as much information as you can. Each completed form is reviewed carefully so that we can learn about your home and family to help us determine if we have a dog that is right for you. There are no truly wrong answers, unless you refuse to agree with any of our conditions of adoption, so please - enjoy the process.

Personal Information Name: ______________________________________________________________ Age: __________

Address: ____________________________________________________________________________

City, State, Zip: _______________________________________________________________________

Occupation:_________________________ Employer:________________________________________

Nearest large city with a major airport: _____________________________________________________

Phone: _________________________ Email: ______________________________________________

What is the best way for us to contact you? ____ Phone ____ Email

Are you in the process of applying for another dog? ____Yes ____No

If so, when and with which group(s)?_____________________________________________________

__________________________________________________________________________________

What is the status of the application(s)?___________________________________________________

___________________________________________________________________________________

Describe yourself your energy level, your interests, your favorite activities, etc.

Describe your ideal dog its energy level, personality, level of training and special skills, etc.

Because dogs often have special needs, please tell us what types of behaviors, medical conditions, etc. you could, and could not, live with in an adopted rescue dog.

Capt HowdyCross-Out

Adopter Information Form Page 2 of 6 6-Jun-06

Personal References Please provide us the names of two individuals (other than family members) who are familiar with your experience as a pet owner. (Please obtain their permission before listing them here.)

Name: __________________________________________ Relationship:________________________

Phone Day: _____________________ Evening: ___________________ Best Time to Call: _______

Email:_________________________________________________

Name: __________________________________________ Relationship:________________________

Phone Day: _____________________ Evening: ___________________ Best Time to Call: _______

Email:_________________________________________________

Your Home and Yard Your home is a: House ____ Condo/Co-op ____ Apartment ____ Mobile Home _____

With a yard _____ Without a yard _____

How long have you lived in this home? ___________ If less than one year, please provide your

previous address and length of time you lived there. __________________________________________

____________________________________________________________________________ ____________________________________________________________________________________

Describe the neighborhood is it on a busy street or in a rural setting?____________________________

Do you ____ Own or ____ Rent your home?

If you rent, you must provide written consent from your landlord to bring animals onto the property. Please provide the following, and attach a letter of consent to this application.

Landlords Name: _____________________________________________________________________

Phone: _________________________

Do you have any neighborhood restrictions/homeowners association rules which might preclude your ability to have a dog in your home? ____ Yes ____ No

Do you have a fenced yard or fenced in area for the dog to use? ____ Yes ____ No If yes, what type of fencing? _________________________________ Is it attached to your house and accessible from a door? ____ Yes ____ No Height of Fence: ____________

If you do not have a fenced yard, how do you plan to exercise the dog? __________________________

____________________________________________________________________________________

And where do you plan for the dog to go to eliminate? ________________________________________

____________________________________________________________________________________

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Your Family and Extended Family How many adults live in your home? __________

Name M/F Occupation

_____________________________________ _____ ____________________________________

_____________________________________ _____ ____________________________________

_____________________________________ _____ ____________________________________

_____________________________________ _____ ____________________________________

How many children are in your immediate family and live in the home? __________

Name M/F Age Activities

_____________________________________ _____ _______ ___________________________

_____________________________________ _____ _______ ___________________________

_____________________________________ _____ _______ ___________________________

_____________________________________ _____ _______ ___________________________

_____________________________________ _____ _______ ___________________________

Is everyone in the family in agreement with the idea of adopting a dog? ____ Yes ____ No - Explain _________________________________________________________

Are there regular visitors to your home (human or animal) with whom your new dog must get along?

Name Relationship Age M/F Frequency of Contact

_______________________________ _______________ _____ _____ ____________________

_______________________________ _______________ _____ _____ ____________________

_______________________________ _______________ _____ _____ ____________________

_______________________________ _______________ _____ _____ ____________________

Please identify any of these people who might have difficulties interacting with the dog and for what reason:

Your Pets and Activities

Do you currently own another pet or pets? If so, list type of animals, breed, names, ages and sex (spayed/neutered or not).

Dog/Cat/Other Breed Name Age M/F Spayed/Neutered?

____________ ________________ _______________ ____ ______ ___________

____________ ________________ _______________ ____ ______ ___________

____________ ________________ _______________ ____ ______ ___________

____________ ________________ ________________ ____ ______ ___________

____________ ________________ ________________ ____ ______ ___________

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What types of activities do you participate in, or plan to, with your dog? (Check all that apply.)

____ Conformation ____ Obedience ____ Agility ____ Frisbee ____ Herding

____ Therapy ____ Jogging ____ Walking Other _________________________________

Do you now, or plan to, compete? ___ Yes ___ No If yes, any titles? _________________________

Do you now, or plan to, train regularly? ____ Yes ____ Hours a week ____ No

Where do you, or will you, train or find training advice?

Do you, or will you, train using Positive Reinforcement? ____ Yes ____ No

If you answered No, please explain your training methods.

Please list the names of all pets that you have owned in the last 10 years and the reason they are no longer living with you.

Dog/Cat/Other Name and Breed Years Owned Reason

________________ ________________________ ___________ __________________________

________________ ________________________ ___________ __________________________

________________ ________________________ ___________ __________________________

________________ ________________________ ___________ __________________________

________________ ________________________ ___________ __________________________

________________ ________________________ ___________ __________________________

________________ ________________________ ___________ __________________________

Are all current pets up to date on vaccinations? ____ Yes ____No

Are all of your dogs currently on heartworm preventative? ____Yes ____No

If so, what kind?_____________________________

Do you use flea control on your pets? ____Yes ____No

If so, what kind?_____________________________

Are all of your current pets altered? ____Yes ____No

If not, please explain.___________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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Have you ever surrendered an animal to a shelter or rescue? ____Yes ____No

If so, why?_______________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Do you understand that the dog will have an adjustment period of several weeks after adoption that could involve housetraining accidents or other behaviors that are out of character for the dog? ____Yes ____No

Are you willing to deal with these issues and work with your dog? ____Yes ____No

Do you have a regular veterinarian? ____ Yes ____ No If you have owned pets in the last 10 years and do not have a regular veterinarian, please explain ________________________________________

____________________________________________________________________________________

Your Current, or Future, Veterinarians Name: _______________________________________________

Address: ____________________________________________________________________________

Phone: _____________________________________ Fax: __________________________________

(Current, Future, and Past Veterinarian information should include any vaccination clinics, pet store veterinarians, etc.)

Any Past Veterinarians within the last ten years:

Name:____________________________________________________________________________

Address:__________________________________________________________________________

Phone:_______________________________________ Fax:_________________________________

Name:_____________________________________________________________________________

Address:___________________________________________________________________________

Phone:_______________________________________ Fax:_________________________________

Name:_____________________________________________________________________________

Address:___________________________________________________________________________

Phone:_______________________________________ Fax:__________________________________

Your Living Arrangements

If you adopt a dog, where will s/he spend the day? ____ Loose indoors ____ Crate

_____ Basement ____ Garage ____ Fenced Yard ____ Kennel ____ Doggy DayCare

____ w/Relatives Other:_____________________________________________________________

On average, how many hours will the dog spend without human company each day? ________

Where will dog spend the night ___ Loose indoors ____ Crate ____ Basement ____ Garage

____ Fenced Yard ____ Kennel Other:_________________________________________________

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Conditions of Adoption In order to protect our dogs, we need you to agree to some basic conditions of adoption. Please initial your understanding of each item listed below.

You understand that CANINE PET RESCUE requires all adopted dogs to be spayed or neutered. ________

You understand that if you adopt a CANINE PET RESCUE dog, you are required to license the dog and provide regular and preventative veterinary care. _______

You agree to a pre-adoption home visit and agree to allow CANINE PET RESCUE representatives post-adoption access to your home and the dog. ________

You agree to contact CANINE PET RESCUE and return the dog to CANINE PET RESCUE should your interest in the dog or your circumstances change where you cannot keep the dog. ________

Canine Pet Rescue CANINE PET RESCUE does request an adoption fee, which helps us cover some of the expenses incurred in rescue and rehabilitation of animals in need. Anything received above that amount is a tax-deductible donation, and is greatly appreciated. Standard adoption fees are $150-300. Fees can be higher or lower depending on the particular circumstances of the dog you are adopting.

Again, thank you for contacting CANINE PET RESCUE with your interest to adopt one of our very special dogs. A CANINE PET RESCUE representative will be in touch with you.

Please note that we do reserve the right to refuse to adopt a CANINE PET RESCUE dog to any individual for any reason whatsoever.

By signing this document, I authorize CANINE PET RESCUE Corp. to contact my listed references and my veterinarian to discuss my pet owning and keeping abilities, and to share that information with other rescues and shelters. By signing, I state that I have never been arrested for, or convicted of, animal abuse or neglect.

________________________________________________________ ___________________

Signature (Date)

Name: Julie NicholsAge: 41Address: 316 Jacobs LnCity State Zip: Statham, GA. 3066Occupation: UnemployedEmployer: Nearest large city with a major airport: AtlantaPhone: 678-451-7099Email: julienichols9@gmail.comWhat is the best way for us to contact you: XPhone_2: Are you in the process of applying for another dog: Yes: XIf so when and with which groups 1: If so when and with which groups 2: What is the status of the applications 1: What is the status of the applications 2: Name_2: Nick ToneyRelationship: FriendPhone Day: 678-698-3179Evening: Best Time to Call: 12-4Email_2: nicktoney@gmail.comName_3: Solomon SummersRelationship_2: FriendPhone Day_2: 706-968-3008Evening_2: Best Time to Call_2: Email_3: House: XCondoCoop: Apartment: Mobile Home: With a yard: XWithout a yard: How long have you lived in this home: 4 yearsprevious address and length of time you lived there 1: previous address and length of time you lived there 2: undefined: Describe the neighborhood is it on a busy street or in a rural setting: more ruralDo you: XOwn or: Landlords Name: Phone_3: dog in your home: Yes_2: XDo you have a fenced yard or fenced in area for the dog to use 1: Do you have a fenced yard or fenced in area for the dog to use 2: Yes_3: XIs it attached to your house and accessible from a door: Yes_4: XHeight of Fence: If you do not have a fenced yard how do you plan to exercise the dog 1: We take our dogs out on leashes If you do not have a fenced yard how do you plan to exercise the dog 2: in our yard when they need to use the bathroom or play.And where do you plan for the dog to go to eliminate 1: Our yardAnd where do you plan for the dog to go to eliminate 2: Your Family and Extended Family: 2Name 1: Mark NicholsName 2: Julie NicholsName 3: Name 4: MF 1: MMF 2: FMF 3: MF 4: Occupation 1: GlazierOccupation 2: UnemployedOccupation 3: Occupation 4: How many children are in your immediate family and live in the home: 0Name 1_2: Name 2_2: Name 3_2: Name 4_2: Name 5: MF 1_2: MF 2_2: MF 3_2: MF 4_2: MF 5: Age 1: Age 2: Age 3: Age 4: Age 5: Activities 1: Activities 2: Activities 3: Activities 4: Activities 5: Is everyone in the family in agreement with the idea of adopting a dog: XNo Explain: Name 1_3: NoName 2_3: Name 3_3: Relationship 1: Relationship 2: Relationship 3: Relationship 4: Age 1_2: Age 2_2: Age 3_2: Age 4_2: MF 1_3: MF 2_3: MF 3_3: MF 4_3: Frequency of Contact 1: Frequency of Contact 2: Frequency of Contact 3: Frequency of Contact 4: Please identify any of these people who might have difficulties interacting with the dog and for what reason: DogCatOther 1: DogDogCatOther 2: DogDogCatOther 3: DogDogCatOther 4: DogCatOther 5: Breed 1: Shepherd MixBreed 2: Terrier MixBreed 3: Blue HeelerBreed 4: Breed 5: Name 1_4: JoeyName 2_4: PixieName 3_4: JakeName 4_3: Name 5_2: Age 1_3: 10Age 2_3: 9Age 3_3: 1Age 4_3: Age 5_2: MF 1_4: MMF 2_4: FMF 3_4: MMF 4_4: MF 5_2: SpayedNeutered 1: YesSpayedNeutered 2: YesSpayedNeutered 3: YesSpayedNeutered 4: SpayedNeutered 5: Conformation: Jogging: Obedience: Agility: Frisbee: Herding: Therapy: Walking: XOther: If yes any titles: Yes_5: Hours a week: No: XYes_6: XNo_2: DogCatOther 1_2: DogDogCatOther 2_2: DogDogCatOther 3_2: DogCatOther 4_2: DogCatOther 5_2: DogCatOther 6: DogCatOther 7: Name and Breed 1: KaneName and Breed 2: ChanceName and Breed 3: Name and Breed 4: Name and Breed 5: Name and Breed 6: Name and Breed 7: Years Owned 1: 15Years Owned 2: 13Years Owned 3: Years Owned 4: Years Owned 5: Years Owned 6: Years Owned 7: Reason 1: Put to sleep at 15Reason 2: Put to sleep at 13Reason 3: Reason 4: Reason 5: Reason 6: Reason 7: Yes_7: XNo_3: Yes_8: XNo_4: If so what kind: We use holistic preventative HWPYes_9: XNo_5: If so what kind_2: We use holistic garlic and yeastYes_10: XNo_6: If not please explain 1: If not please explain 2: If not please explain 3: Have you ever surrendered an animal to a shelter or rescue: Yes_11: XIf so why 1: If so why 2: If so why 3: housetraining accidents or other behaviors that are out of character for the dog: XYes_12: Are you willing to deal with these issues and work with your dog: XYes_13: Do you have a regular veterinarian: XYes_14: regular veterinarian please explain 1: regular veterinarian please explain 2: Your Current or Future Veterinarians Name: Jefferson Animal HospitalAddress_2: Jefferson, GA. 30666 We have done our own vaccinations at home for the past few years except for rabies.Phone_4: 706-367-5161Fax: Name_4: Some rabies shots done by vets from PawsPlusAddress_3: Tractor Supply CompanyPhone_5: Fax_2: Name_5: Address_4: Phone_6: Fax_3: Name_6: Address_5: Phone_7: Fax_4: If you adopt a dog where will she spend the day: XLoose indoors: XwRelatives: Basement: Garage: Fenced Yard: Kennel: undefined_3: Other_2: On average how many hours will the dog spend without human company each day: 6Loose indoors_2: XCrate: Basement_2: Where will dog spend the night: Fenced Yard_2: Other_3: You understand that if you adopt a CANINE PET RESCUE dog you are required to license the dog and provide regular: JNYou agree to a preadoption home visit and agree to allow CANINE PET RESCUE representatives postadoption access: JNYou agree to contact CANINE PET RESCUE and return the dog to CANINE PET RESCUE should your interest in the: JNdog or your circumstances change where you cannot keep the dog: JN2012-03-08T14:00:33-0500Julie Nichols

Date: 3-8-2012If ansswered "No," please explain: Describe yourself: My husband and I are animal lovers who mostly stay around home, but like to walk and canoe when the weather permits.Describe your ideal dog: We are looking for a dog that will be a playmate for one of our other dogs, jake, a 14 month old Blue Heeler. We hope for a dog that likes to play, is energetic, and also affectionate with people and at least tolerates cats.What could you NOT live with in an adopted dog?: Explain: Identify any of these people who might have difficulites with the dog and what reason: Where do you, or will you train or find training advice?: Submit: