Date of Birth:

Your name:

Email:

Name of animal in which you are interested:

Breed/Description:

Release for Veterinary Reference (to be completed by potential adopter):

Do you have veterinary reference?:

Name:

Name of Veterinarian:

Street Address:

City:

ZIP Code:

Phone:

I hereby give permission for any veterinarian providing service to me to release medical information on any/all of my animals, to Freedom Service Dogs. [If you do not have a veterinarian reference, please provide two personal references in the space provided at the end of this form.] Your Electronic Signature:

A rescued animal will have a period of adjustment which may be from two weeks to a few months. Are you willing to commit to this adjustment period and follow recommendations for a smooth transition?:

Address (Include City & Zip):

Home phone:

Work Phone:

Cell Phone:

Do you own or rent?:

Type of residence (House, apartment, etc):

How long at this residence?:

Does your lease permit pets?:

Are there breed or weight restrictions?:

Is there a pet deposit required (if yes, we will require proof that deposit was paid)?:

Landlord’s Name:

Landlord’s Phone Number:

Are you a member of a Homeowner’s Association?:

Do you have a copy of the bylaws, policies, regulations etc. especially as they relate to owning a pet?:

Employer:

What are your hours?:

Spouse/Partner’s Employer:

What are their hours?:

Work or Cell Phone:

How many hours would your pet be alone while you are at work?:

Where will the pet stay while you are gone?:

Do you have a pet door?:

Are you willing to install one?:

How do you plan to handle the pets elimination needs while you are not home?:

Where will the dog sleep?:

Have you ever housetrained a dog?:

Please describe how it was done:

Do you or your spouse/partner travel frequently?:

How often?:

What will you do with the pet when you travel?:

What will you do with the pet if you have to move?:

Are you willing/able to purchase and use a crate if needed or advised?:

Are you willing/able to attend approved obedience or training classes with the dog?:

Are you familiar with the term “Socialization”?:

Are you prepared to correctly socialize your dog with other people and dogs?:

Do you consider yourself to be:

How do you plan to exercise your dog?:

Do you live alone or have a family?:

Does everyone in the household want this particular dog?:

Does anyone in the household have allergies?:

Are they allergic to animal dander?:

Do you have children?:

What are their ages?:

Do you have grandchildren?:

Do they live in the home, or visit frequently?:

How often do they visit? :

Do you have a fenced yard? :

What type and Height? :

Is the yard secured? :

Do you have a pool? :

Is the pool fenced off? :

Have you ever owned a dog of this breed/mix before? :

Have you ever owned a rescue dog? :

Where did they come from? :

Have you ever applied to another organization and been declined? :

If “yes”, please explain :

Have you ever relinquished or re-homed a pet? :

If so, why?:

Where did this pet end up? :

Is there a limit on the amount you could spend on your dog for medical care? :

How much is too much? (please do not use a "$" sign, for example, write as 100 or 10,000):

Would you ever consider euthanizing your pet because of medical costs?:

What qualities are you specifically looking for in a pet?:

What traits or characteristics are you sure you do NOT want? :

Do you give permission for an FSD representative to visit your home prior to adoption both before and after adoption to do follow up?:

How many animals have you had?:

Pet Ownership History:

Please provide details about any current or past pets you have had. If needed, please write on the back or attach another sheet.:

Pet 1 Name:

Type:

Where did you acquire this pet?:

Breed/Description:

Length of Ownership:

Age of Animal:

Heartworm Preventative given?:

Kind and Date of last treatment:

Date of Last shots DHLPP:

Bordatella:

Rabies:

Where did this pet sleep?:

Where did this pet stay while you were away from home?:

Were there any medical or behavioral issues?:

Please describe:

Where is this pet now?:

Pet 2 Name:

Type:

Where did you acquire this pet?:

Breed/Description:

Age of Animal:

Heartworm Preventative given?:

Kind and Date of last treatment:

Date of Last shots DHLPP:

Bordatella:

Rabies:

Where did this pet sleep?:

Where did this pet stay while you were away from home?:

Were there any medical or behavioral issues?:

Please describe:

Where is this pet now?:

Pet 3 Name:

Where did you acquire this pet?:

Breed/Description:

Length of Ownership Pet #3:

Age of Animal:

Heartworm Preventative given?:

Kind and Date of last treatment:

Date of Last shots DHLPP:

Bordatella:

Rabies:

Where did this pet sleep?:

Where did this pet stay while you were away from home?:

Were there any medical or behavioral issues?:

Please describe:

Where is this pet now?:

Please provide 2 personal or professional references as related to your animals.:

Name 1:

Relationship:

Email:

Phone Number:

How long known:

Address:

Name 2:

Relationship:

Email:

Phone Number:

How long known:

Address:

Signature:

Date of Application: