SMALL DOG RESCUE 
 
PUREBRED AND MIXED BREED 
ALL DOGS SPAYED OR NEUTERED
Fields  marked with a * Must Be Answered
Also, some fields  are noted as follows (This is a required question, please answer)  
answer these fields specifically as possible.  
Failure to fill in these fields will cause your application to be rejected
*First and Last Name
*Address
*City:                                       *State:                          *Zip:      
*Home Phone:                               Work Phone:                         *Evening Phone:
Email Address:        
Best time to contact you:  
*Number of Adults in your home:
*Ages of Adults in your home - check all that apply:
	18 - 25 ______
	26 - 35 ______
	36 - 45 ______
	46 - 55 ______
	56 - 66 ______
	67 - 77 ______
	78 - 88 _______
	89+ ___________
*Ages of children in your household (including children who are visitors): 
		
*What kind of dog are you looking for:
   
*What activity level in a dog are you looking for? Very active, moderately active, low level of activity:   
(This is a required question, please answer)

*Have you had dogs before?                          What kind(s) 
*What happened to your dog(s)? 

*Will your dog primarily be an indoor or outdoor dog?  
(This is a required question, please answer)

*Do you have a doggy door?                                      If not, would you install one?   
(This is a required question, please answer)

*Type of residence: House              Apartment                    Other e.g.: Condo/Townhouse (please explain)
___________________________________________________________________________________________________
*Do you own or rent your home?
*Do you have a fenced yard?                 If yes, Type of Fence e.g.: Wood, Block, Chain link, 
Other: ___________________________________________________________________________________________________________ 
(This is a required question, please answer and please be specific about fence type)


*Do you have a pool?                If so, is it fenced? 

*Have you discussed this adoption with all household members? 
*How do the other household members feel about adopting a dog? 

_____________________________________________________________________________________________________
*Please list any other pets or animals in your home: 

_____________________________________________________________________________________________________
*Do you have a regular Veterinarian? If so, please give his/her name and phone number: 
*Do you have a regular Groomer? If so, please give his/her name and phone number: 
*How many hours per day will your dog be left alone? 
*When you travel or go on vacation, what will you do with your dog? 
_____________________________________________________________________________________________________
*A dog can live for 15 or more years. Are you ready to make that kind of commitment? 

_____________________________________________________________________________________________________

Please email me: contactusnow@tikiblackdog.org  your application to me.