Adoption Application

Name of applicant:________________________________________________

Name of co-applicant:_______________________________________________

Home address: ____________________________________________________

City: _________________________State:____________________Zip:_______

Home Phone: ______________Work Phone:______________________

E-mail address: __________________________________________________

How did you hear about us? ______________________________________

Have you previously adopted a Golden Retriever? NO YES *name*:_____________________________________________

Why do you want to adopt a Golden Retriever?: ____________________________________________________

Do you have young children in the home, if so, what are their ages? ____________________________________________________

Does anyone in the household have allergies to animals? ____________________________________________

Does anyone in the family have a physical disability or serious health conditions? _____________________________________________________________

Will this be your first dog?: NO YES

Will this be your first Golden Retriever?: NO YES

Have you ever sold, given away or surrendered a pet to a shelter? NO YES If Yes: ____________________ ________________________________________

Please list all current pets in your household:

TYPE: ________________BREED: ____________________AGE:___________

TYPE: _______________ BREED: ____________________AGE:___________

TYPE:__________________BREED:____________________AGE:___________

TYPE: _________________BREED:___________________AGE:___________

How do your current pets get along with dogs? ___________________________________________________

Have you ever bred a dog? _____________________________________________________________________

Do you live in a: HOME   APARTMENT      TOWNHOUSE/CONDO        DUPLEX

Do you own or rent?: OWN RENT If rent, are pets allowed?: YES NO

Please describe the area you have for the dog when outside: __________________________ _____________________________________

Who will be primarily responsible for the dog? _____________________________________________________

Is anyone regularly at home during the day? _______________________________________________________

How long, on an average, will the dog be alone during the day? _______________________________________________________

Will your dog have run of the entire house? _______________________________________________________

Where will your dog sleep at night? ______________________________________________________________

Will your dog be kept in a garage or outdoors spaces? _______________________________________________

Will your dog ever live outside in a yard or kennel? _________________________________________________

Will your dog be tied outside if you can not keep an eye on it? ________________________________________

Will your dog be allowed to run free off leash when outside of your fenced yard? _______________________ ________________________________________

If your adopted dog requires it, are you willing to get a crate and use it? _______________________________ _________________________________________

Will your dog be allowed on the bed or other furniture? _____________________________________________

(Above is for placement information only, dogs do not have to be allowed on furniture)

Are you aware that Golden Retrievers are very active dogs and require significant daily exercise? ___________________________________________________

Are you aware that Golden Retrievers shed all year round? _______________________________________________________________

Are you aware that Golden Retrievers are large and could knock over children or elderly? ________________________________________________________

Do ALL members of the family want a Golden Retriever? _______________________________________________________________

Do you plan to groom the dog yourself or use a groomer? _______________________________________________________________

Would you consider adopting a senior Golden? YES NO

Would you consider adopting a special need Golden? YES NO

Would you consider adopting a pair of Goldens that can not be separated? YES NO

Would you prefer a neutered male or a spayed female Golden? _______________________________________________________________

In order to complete this application, we will need a reference from your veterinarian.

Please fill out: Veterinarians/Hospital Name: _________________________________________________________________

Address: _________________________________________________________________

City, State, Zip: _________________________________________________________________

Telephone Number: __________________________________________________________________________

Your Pet’s name(s): ___________________________________________________________________________

Are/were your pets on flea or tick prevention? YES NO

Are/were your pets on Heartworm Prevention? YES NO

I hereby authorize my veterinarian to release confidential information about my pet(s) and my pet(s) care.

Applicant’s Signature: _________________________Date: _______________

Co-Applicant’s Signature: ____________________________Date: _________