PitEssentials Rescue

PitEssentials Rescue, Inc. Adoption Application
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you live in city limits*
Home Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
E-mail*
Birth Date*

MonthDayYear
Occupation*
How many adults (21 and older) in your household*
How many individuals under 21 in your household*
What are the ages of the individuals under 21*
How far would you drive to meet a dog*
Dog(s) you are interested in meeting*
Are you looking for a*

MaleFemaleEither
Do you prefer a*

PuppyAdultEither
Do you own any of the following*

DogCatOtherNo animals
If yes please list breed, sex, age of all
Do any of the above live outside*

YesNoN/A
If yes please explain
Which heartworm and flea prevention do you use*
Are all your animals spayed or neutered*

YesNoN/A
If no please explain
Housing*
If you rent or live in an apartment please provide name and phone number for verification
Does your municipality have breed specific restrictions*

YesNoDon't know
If yes please describe the nature of the restrictions
IMPORTANT: Many homeowner's insurance companies have breed blacklists which include, but are not limited to, pit bulls, American Pit Bull Terriers, American Staffordshire Terriers, Staffordshire Bull Terriers, Rottweilers, Dobermans, Akitas, American Bulldogs, Chows and wolf-hybrids and will not insure you if they reside in your home or may cancel your insurance if you add a dog of these breeds to your home. Please check your homeowner's insurance policy regarding breed discrimination BEFORE adopting a pit bull type dog. Landlords may also have these same breed restrictions due to their insurance policies.
Is your yard fenced in*

YesNo
If yes please list type and height
Dog's living situation (check all that apply)*

Dog will be house pet, living inside with familyDog will live in basement or garageDog will live outdoorsDoghouse providedGuard dog
How many hours a day will the dog be home alone*
When home alone dog will be (check all that apply)*

In a crate, wire cage, or dog pen insideIn a kennel outsideTied up outsideDog will be loose outsideDog will be loose inside
How will you exercise the dog (check all that apply)*

Leash walks every dayWill have cable or dog run in the yardWill be free to run in fenced yardWill have supervised access to unfenced yardWill be free to roam around (Off leash and unsupervised in unfenced areaWill bring to dog park (Public are where dogs can run and play together off-leash)
If you have previous breed experience please explain
Have you ever sold, gave away, or surrendered an animal to a shelter?*
If yes please explain
Veterinary Clinic and Phone Number*
Enter the message as it's shown*
Click to edit*

MonthDayYear
Signature*
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PitEssentials Rescue, Inc. Adoption Application