First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County*

Email*

Home Phone*

Work Phone
x

Cell Phone*

Alt Email

Date of Birth: *

Occupation:*

List ALL other people living in the home and include the following FOR EACH: (1) Full Name, (2) Relationship to Applicant, (3) Age, (4) Phone Number, (5) Email Address. If not applicable, enter "none":*

List ALL people living in the home (not listed above) and include the following for each: (1) Full Name, (2) Relationship to Applicant (3) Age . If not applicable, enter "none":*

Have all adult household members (Spouse/Partner, Roommate, Parents, etc.) agreed upon adopting a pet?*
Choose one: Yes No

Select the NAME OF THE DOG you are interested in adopting FROM THE DROP-DOWN LIST BELOW. *
Choose an animal: * Any Dog Acacia Aiden GCH Allegra Barkville Amelia Anastasia Anna RM Any Cat Apollo RABBIT Arnold Artemis Louisiana Athena RABBIT Baby KITTEN Bailey GCH Barbie Barkville Barton Bavaria Lizman Bela RM Bindi Steele Binx Boeing Lonestar* Boone Steele Branch Brock Lonestar Brook Lizman Bryce SCAS Butter RABBIT Cakie Calliope Candy KITTEN Cedar NJ Chaplin Cheetah Lonestar Chenille Barkville Chiffon Barkville Chippy RABBIT KIT ChooChoo Barkville Cindy GCH Cleo Cleo *NEEDS AN ANGEL* GCH Clover RABBIT Clyde Coco KITTEN Coco Ohio Connors GCH Cow Crackle KITTEN Crockett Lonestar Dakota's Albert KITTEN Dakota's Archie KITTEN Dakota's Linus KITTEN Dakota's Marie KITTEN Dakota's Niko KITTEN Dakota's Peter KITTEN Daphne's Monet KITTEN Daphne's Picasso KITTEN Daphne's Warhol KITTEN Dave (& Guns) Dixon-BONDED Dave RABBIT Delilah's Katara Delilah's Suki Diamond Beaufort Diamond NJ Diesel the Doberman Louisiana Dillon Spalding Dingo Lonestar Dodger Louisiana Dorothy RM Dottie Dixon Dozer Wilson SCAS Drew Steele Duncan Louisiana Elma Lonestar Epiphany RPS Excelsis Walton Farrah Dixon Feldspar Lizman Fred GCH Gator Lonestar Gator RM Gene Parmesan Gideon GCH Gidget Lonestar Ginger Lizman Gizmo Steele Goggles Lizman Goldie (Bee Lonestar) Granny Smith Gretchen Wilson SCAS Guns (& Dave) Dixon-BONDED Hannah Steele Harry Hendrix RM Huck Bailey Hutch Lonestar Idgie Barkville Isabelle KITTEN Ivanna RM Jeff Barkville Jerry Lizman Jinx GCH Jitterbug Lonestar Jolie Juniper Jupiter RABBIT Karol GCH Kasia KITTEN Kilo GCH Kim KITTEN Kimchi and Willow GUINEA PIGS Kiwi Barkville Kiya Lizman Koa Barkville Kobe Lizman Korra Lonestar Kubo Lonestar Kylo Lonestar* Kyra Lonestar Lamb RABBIT KIT Layla Momma Dessin Leela Barkville Leo Sayer Barkville Leo SCAS Leshy GCH Lexie Wilson SCAS Lilith RM KITTEN Lilly Lilly KITTEN Lily Liquor Little T Llama Lonestar Logan Dog & Tia Cat (BONDED PAIR) Loki NJ Lola 2 RABBIT Lola NJ Lola RABBIT Lolly NJ Lorelei DEAF GCH Louise RM Lucky Havard Lucy Ross Lucy's Batman KITTEN Lucy's Pickles KITTEN Lulu KITTEN Luna Luna's Comet Rabbit KIT Luna's Mars Rabbit KIT Luna's Pluto Rabbit KIT Luna's Saturn RABBIT KIT Lynx KPS Lynx KPS Mack Bailey Madalyn TRIPOD Barkville Mae Mae Mae Mae's Dimitra KITTEN Maggie Lizman Mahomes Louisiana Maise Lizman Malachi Mandy's Adonis KITTEN Mandy's Freckles KITTEN Mandy's Harley KITTEN Mandy's Rexx KITTEN Mandy's Spot KITTEN Mandy's Trixie KITTEN Mango GCH Mardi Barkville* Marsh and Mallow GUINEA PIGS Marshmallow Mavi Lizman Max McGee Lonestar Melody Milo Milo Lizman Milo RM Mimi Mirage Bailey Missy Molly's Florence KITTEN Molly's Milan KITTEN Molly's Rome KITTEN Molly's Venice KITTEN Moon RPS Morris (Momo) Mr Zack Munchkin Mystica Nacho Nash (Chip Lonestar) Necco Noah Nutmeg RM Nuttles Olive Mini Pittie Ollie (Noah Alabama) Onyx RM KITTEN Oreo GCH Oreo RM KITTEN Osbert Lizman Oscar Lonestar Oswald GCH Owen Hill Paisley Barkville Paisley SCAS Paris KPS Pascal Clayton Pebbles NJ Pedro Lowrider Bean Penny Petey Ward Steele Pickles Newark Pirate Lowrider Bean Poly Pong Lonestar Pongo Beaufort Poppy KITTEN Poppy Lonestar Poppy RABBIT Presley Lonestar Prince Pumpkin & Spice GUINEA PIGS Regan Barkville Rex RM Rico Barkville Rocky Rosie Barkville Rosie's Luna Rosie's Prince Rosie's Stella Rowan GCH Rubie (Hagrid Clayton) Rune Rusty Lizman Sadie Ohio Salem GCH Sally (Prim Caddo) Sammy RPS Sandy Sandy NJ Screech GCH Seti Shadow/King Havard Shelby (SADIE) Shyla GCH Skyliza Barkville Snicker's Rain Lonestar* Snowflake Steele Spike RM Stanley Martin Steele Starz KITTEN Stella Stitch NJ Sunny Lonestar Sweetpea Sydney GCH Tabby RM Teddy GCH Tequila Barkville Thor NJ Tia Cat & Logan Dog (BONDED PAIR) Tiger SCAS Tigris RM Tilly Lonestar Tito Rico Toast Toby SCAS Toree GCH Tori GCH Tucker Daniels Turtle NJ Twist Lonestar Valentina's Bordeaux KITTEN Valentina's Marseille KITTEN Valentina's Orleans KITTEN Valentina's Versailles KITTEN Vanilla Lonestar Velvet Barkville Violet Beauregarde Lonestar Wilbert Newark Winter* XP - Ace NJ XP - Jasmine SENIOR XP - Milo NJ XP Ace - Bernardsville, NJ XP Butter - Bloomfield, NJ XP Cane - Metuchen, NJ XP Cleopatra, Neffertiti, Cesar, Hercules/Newark XP Jaskier - Wayne, NJ XP Jelly - South Plainfield, NJ XP Jessie - Blairstown, NJ XP Raven XP Skylar - Somerville, NJ XP Valkyrie (Kyrie) - NJ XP Xena - Newark, NJ

Other than the dog listed above, are there any other dogs you are interested in adopting? If so, please list names.

CURRENT PETS: List any animals currently living in your home. For EACH PET be sure to include all of the following information: (1) Name, (2) Species, (3) Breed, (4) Age, (5) How long has the pet been residing with you, (6) Spayed/Neutered, if not, why? If you do not currently have any pets in the home, enter "none".*

PAST PETS: List any pets you have PERSONALLY owned. For each, include ALL of the following information: (1) Name; (2) Species; (3) Breed; (4) How long did your pet(s) reside with you; (5) Were pets spayed/neutered, if not, why? (6) When did your pet pass away? If the pet is not deceased but no longer living with you, please explain. If you have never owned a pet before, enter "NONE".*

VETERINARIAN(S): List the name, city, state, and phone numbers of ALL veterinarian(s) who have treated your current and past pets. IMPORTANT: Contact the vet(s) and inform them that Eleventh Hour Rescue will be calling for a "vet check" and give your permission for them to speak with us. If you've never used a vet, enter "NONE".*

REHOMED A PET?: We understand that occasionally there are circumstances where a pet can no longer stay in the home. Have you ever had to give up a pet? What were the circumstances, and what was the outcome for the pet? If you have never rehomed a pet, enter "none".*

Provide THREE (3) personal references. 

Appropriate references are friends, neighbors, clergy, and co-workers. One reference may be a relative that DOES NOT live in the same home as you.

IMPORTANT: Please inform your references immediately upon completion of this application that we will be calling them. 

Reference 1 - Full Name:*

Reference 1 - Relationship to Applicant:*

Reference 1 - FULL Address:*

Reference 1 - Phone Number:*

Reference 2 - Full Name:*

Reference 2 - Relationship to Applicant:*

Reference 2 - FULL Address:*

Reference 2 - Phone Number:*

Do you own or rent your home?*
Choose one: Rent Own I live with my parents Other

What type of home do you live in?*
Choose one: House Townhouse Condo Apartment Duplex Mobile Home Other

If you rent, provide your landlord's name and phone number. We will need to contact them to inquire about any pet, breed and size restrictions. IMPORTANT: Please tell your landlord that Eleventh Hour Rescue will be contacting them.

If you own your apartment, condo or townhouse, provide the name and phone number of the Homeowners Association and/or Property Management Company. We will need to contact them to inquire about any pet, breed and size restrictions.

Do you have a secure, fully-fenced area or an electric fence on your property? If yes, describe HEIGHT, TYPE, MATERIAL, AREA SIZE or Electric. If no fenced-in area, write "none". PLEASE NOTE - a fence is not a requirement for approval, but may be required for certain dogs. *

If you do not have a fenced-in yard, please explain how you intend to exercise the dog? If you have a fenced yard, please enter "n/a".*

What activity level would best describe your home?*
Choose one: Quiet (minimal visitors/activities) Moderately busy (some visitors/activities) Very busy (many visitors/activities)

Describe the daily activity level in your household: (choose one)*
Choose one: Not very active - primarily inside activities with minimal outdoor time Moderately active - some outdoor activities Very active - constant outdoor activities

Do you have a preferred age range of a new dog? *Note - we cannot guarantee the ages; the majority of ages listed are approximations. Select all that apply.

Do you have a full-grown size preference? Select all that apply. (*NOTE: We won't know exactly how big a puppy will get since we are often unsure of their breed mix.)

While most of our dogs are MIXED BREED please describe any breed PREFERENCES or AVERSIONS: (example: Looking for a _____, not fond of _____). If you have no input about dog breed - Enter: all breeds *We CANNOT guarantee the breeds in mixed breed dogs*

We often take in WONDERFUL ADULT dogs who LOVE ALL HUMANS but DO NOT LIKE other dogs. Would you consider adopting a loving dog that cannot live with, be around or socialize with other dogs? *
Choose one: Yes No Maybe, depends on the dog

Please check all that apply to the following statement (PLEASE NOTE: we cannot guarantee any of these characteristics). It is ABSOLUTELY CRITICAL that my new dog....

Is anyone in your household allergic to dogs? If so, how is it managed?*

If you have children, have they been around dogs? What are their experiences? What is their comfort level? Are they respectful of dogs and their space? Are they fearful of dogs? Please explain.

What are your reasons for adopting a dog? Select all that apply

If other, please explain

Who will be the primary caretaker for this dog?*

The average yearly cost for a healthy dog is approximately $500-750. Are you financially capable of the yearly vaccine's, routine exams, sick visits and potential surgeries that come as part of owning a dog?*
Choose one: Yes No

On average, how long will the dog be left alone each day?*

What arrangements will you make if you are away for long period of time (i.e. vacation, business travel, etc.)?*

Where will the dog be kept when you are not home? (For example, outside in yard or pen, inside roaming free, inside in crate or confined area)*

Where will the dog sleep at night?*

Are you willing to take the time to housebreak a dog?*
Choose one: Yes No

Do you understand that changing a dog’s environment and schedule may cause the dog to have accidents in the home?*
Choose one: Yes No

How do you plan on training your new dog?*

Are there any habits or behaviors you will not tolerate from your dog?*

In which of the below instances might you consider surrendering your dog? (check all that apply)

For those items that you checked the kind of personal situations where you would consider surrendering your dog, please elaborate:*