apply2adopt

CSCAGDR ADOPTION APPLICATION

Name:

Co-Applicant's Name:

Street Address:

Home Phone:

Your Age/Co-Applicant's Age:

E-mail Address:

Driver's License: State:

Number: *

Social Security Number: *

Employer Name:

Employer Address:

Do you have any children?

If so, please list their ages:

Type of Residence:

Landlord's Name:

Phone Number:

Are you willing to permit a home-check by a CSCAGDR representative?

Fenced Yard?

Type and height of fencing:

How often will you walk the Dane?

How long will Dane be left alone during the day?

Where will the Dane stay when he/she is home alone?

Where will the Dane sleep at night?

Do you prefer any particular color of Dane? Choose all that apply.

Do you have a preference about cropped/natural ears?

Which age groups are you interested in? Choose all that apply.

How active would you like your Dane to be?

Are you willing to take the Dane to obedience classes?

What kind of temperament would you like your Dane to have?

Status of Prior Pets:

Name/Type of Pet/Cause(s) of Death

Current Pets

Breed/Sex/Age:

Spayed/Neutered?

References:

Veterinarian(s) with prior and present pet records:

Vet Name:

Vet Phone:

Name(s) of Pets Seen:

Vet Name:

Vet Phone:

Name(s) of Pets Seen:

Trainer (Name and Phone Number):

Other (Non-Relative) References: (Name, Phone Number, and Relationship to Applicant)

How did you hear about CSCAGDR?

Any questions/comments/concerns not previously addressed?

Would you adopt a Dane with medical concerns? Please explain what medical concerns you are/are not willing to accept.

Landlord's Address:

* This information is required if adoption is successful. You do not have to give it now. *

City/State/Zip:

Name/Type of Pet/Reason

Name(s):

Last Name on Vet Records:

Would you consider a Great Dane mix?

Would you consider a deaf/blind/vision impaired Dane?

Your initials in each box below will serve as your electronic signature.

There are no charges of animal cruelty or neglect pending against myself or any member of my household.

Neither I nor any member of my household has ever been conviced of animal cruelty or neglect.

I give CSCAGDR permission to contact my veterinarian and those persons I have listed as references and to gather any information deemed necessary to process my application for adoption.

All information given in the application is true to the best of my knowledge and I understand that any false information is reason for denial of my application.

Have you previously or recently applied to any other Great Dane Rescue?

If yes, please list the rescue(s):