Golden Retriever preferred:  Sex Male Female Either   Age 1-3 Any 4-6 >7 years old

Applicant Name:  Age:

                        (Must be at least 18 years old)

Co-Applicant Name:  Age:

Relationship to Applicant: Spouse Parent Guardian Child Roommate Other If other: (please specify)

Street Address:

City:   State:   Zip Code:

Mailing Address (if different than above):

Home Phone:  Cell Phone: Best Time to Call:

E-Mail Address:

Applicant's Employer:

Position:  Phone:

Co-Applicant's Employer:

Position:  Phone:

Questions:

1. Why do you desire to adopt a Rescued Golden Retriever:  Personal Companion Child Companion Personal Protection Guard Dog Breeding Gift Other

            If you answered "Other" please explain:

2. Do you live in a: Apartment Condominium Duplex House Townhouse Other

3. Do you have a fenced yard? Yes No   If yes, what type of fence?  

                                                            And what is its height at its lowest point? Less than 3 feet 3 to 4 feet 4 to 5 feet 5 to 6 feet More than 6 feet

4. Where will this pet be kept during the day?  

                                                    At night?

5. How many adults live in your household? 1 2 3 4 More than 4   Children? None 1 2 3 4 5 6 More than 6   

    What are the children's' ages? (Use the CTRL key for more than one selection)

             0-3 Yrs old 4-6 Yrs old 7-9 Yrs old 10-12 Yrs old 13-15 Yrs old 16-18 Yrs old

6. Is anyone at home during the day? Yes No   Who? Applicant CoApplicant Other Adult in the Home

7. Who will be responsible for caring for this animal? Applicant CoApplicant Other Adult in the Home

8. How many hours will this pet be alone per day? Less than 1 1-4 4-8 More than 8

9. We require that all animals adopted from us be spayed or neutered.  Do you have any reservations or questions about this policy?         No Yes

10. Who will care for this animal when you go on vacation? 

11. If you move, what will you do with this animal? 

12. Are you willing to take responsibility for this pet for the next 10 or more years?  Yes No

13. How much do you expect it will cost to take care of this animal each year?  Please consider the cost of veterinary care, food, grooming, licensing, etc. 

14. Please list all the pets you have owned in the past three years:

    Type                 Sex     Age         Spayed/Neutered?                     Where is it Now?

15. SEVA GRREAT reserves the right to provide the best homes possible for our Goldens.  Please provide the name and phone number of your present veterinary hospital, as well as the name(s) of your pet(s), past or present that were treated there, so we may conduct a reference check. 

Veterinary Hospital                                             Phone No.

Pets’ Names that you have used this Veterinary Hospital for:

16. If you have ever had a pet die at an early age, or due to an accident, please explain the circumstances:

17. If you do not have adequate fencing (i.e. a totally enclosed, secure yard) how will you exercise your dog?

18. Have you ever been convicted of a felony or animal abuse? No Yes

19. How did you hear about GRREAT? Animal Clinic Friend/Family Golden Day Internet Search Magazine Newspaper Other Web Site

20.  Other comments or questions you may have:

I ACKNOWLEDGE THAT ALL THE INFORMATION CONTAINED IN THIS FORM IS TRUE AND CORRECT.  I UNDERSTAND THAT ANY MISREPRESENTATIONS OF FACT MAY RESULT IN THE REMOVAL OF THE ADOPTED  DOG FROM MY HOME BY GRREAT.  GRREAT reserves the right to refuse an applicant if the home situation is incompatible with the needs of a rescued Golden. 

Yes No