First Name:                           Last Name: 

Age: 

Spouse Name:                       Last Name: 

Age: 

 Address 1:  
 
 
City:                State:             Zip: 

Phone:              Cell: 

Employer:                   Employer Phone: 

Spouse Employer:             Employer Phone: 
 
 Reference Information:
 
Driver's License Number :
 
Vet Name:             Vet Phone: 

Date of LastVisit: 
 
 
If you do not have a veterinarian, you will be asked to provide the name and telephone number of one prior to being approved for adoption. 
 
 
When providing Personal References please include at least two reference which is not related to you.

Reference 1Name:                  Phone: 

Reference 1Email:  
 
Reference 2 Name:                 Phone:

Reference 2 Email:  

 
Reference 3 Name:                 Phone: 

Reference 3 Email:  
  
 Environment:
 
 
Number of Children:              Ages: 
 
 
 
Please list the names and ages of anyone else living in your household who are not listed above:

  
 
 
 
 Is everyone in your home in agreement to adopt a Dog ?  Yes               No

 
 
How long have you lived at this address?  

 
 
Describe your current living situation:

 House          Apartment                 MobileHome               Condo

 
 
 
Do You?  Rent                Own                 Live With parents
 
 
 If Renting please provide:

 Landlords Name: 

Landlords Phone: 
 

 

 
What type of environment?  City                 Suburban               Country
 

 
Is there a Yard?   Yes            No

Fence?  Yes               No

 What type and how tall? 
 

 

 

 

 
Gate that can be locked?  Yes                   No

How many hours will the dog be left "alone" per day? 

 Where will the dog be kept while you are working? 
 
 

 
 Adoption Information:
 
 
 Why do you want a Dog ? 

 

 

 
 
 Where will the dog spend most of its time? 

 Have you ever owned a dog:  Yes                 No

 Sex Preference:  Male             Female              No Pref

 
 
 
Age Pref:  Puppy 0-6 Mo              Adolescent 1-2 yr's                Adult 2yrs +

 If interested in a specific dog please enter their name and/or number here: 

 

 
 
   Previous & Current Pet information: 
 
 
Please List all Current pets (Name, age, breed and sex) 
 
 
 
Are your pets ?
 
 
 
Spayed/Neutered?  Yes               No
 
 
 
Current on all required vaccinations?  Yes                  No
 
 
 
Taking Heartworm Preventative?  Yes                 No

If yes what type? 
 
 
 
Please List the pets you've owned in the past 3 yrs who are not listed above and what happened to these pets and why? (Example: Fluffy, Poodle female, passed away at age of 10, old age)
 
 
 
 
 
 
 
 Certification:
 
 
Please read the following very carefully. By signing this adoption application you hereby certify that all the above information is true and correct and agree to the following terms to be considered for adoption of a rescued Dog:

 
 
 
I understand that the previous history and/or heritage of any particular dog is unknown prior to them being accepted into foster care by Vom Blue Rescue.

 
 
I understand that providing any false or misguiding information on this application will result in immediate denial of my application.

 
 
I understand that ALL animals placed by Vom Blue Rescue will be spayed or neutered before adoption or at the age of 6 months or younger by the adopting family,  and will not ask Vom BLue Rescue to deviate from this mandatory policy.

 
 
I understand that if I am approved for adoption, that although I may state a preference that the final decision as to what dog I will be allowed to adopt is that of Vom BLue Rescue and I agree to adhere to their advice.

 
 
I understand that Vom BLue Rescue is under NO obligation to approve my application and reserves the right to deny ANY application without cause or reason.

Vom Blue will take  back  any dog that we have adopted out. We also make this a rule that all of our rescued dogs must be brought back here if the family can no longer keep them.
 
 
I am 18 yrs of age or older, financially and emotionally capable of caring for, training, and providing a stable environment for a Rescued Dog.

I will supply all medical care and every other needs to meet the well-being of this pet.And I will provide proof of vet care to Vom Blue Rescue if required at any time.

Signed_____________________                    Printed name___________________

Date_______________

Send to:

Vom Blue Rottweiler Rescue
Newburgh, Indiana 47630

rottluvr303@yahoo.com