First Name Last Name Street Address City State Zip Code Home Phone Alternate Phone Number E-mail Address Date of Birth Occupation Do you live with
Spouse/Partner Roommate(s) Parents Alone How many adults (21 and over) are in your household? How many individuals under 21 live in your household? What are the ages of the individuals under 21 in your
household? How far could you drive to pick up dog? Name of dog you are interested in adopting. (REQUIRED) Name of dog you are interested in adopting (Second
choice if applicable) Are you interested in adopting a male or female? Do you prefer a puppy or an adult? Prefer dog to be:
Already spayed or neutered Not spayed or neutered Doesn't Matter Dog's Living Situation
Dog will be housepet, living
inside with family Dog
will live in basement or garage Dog will live outdoors Doghouse provided Guard Dog for business or residence Other How many hours a day will the dog be left alone? When home alone, th dog will be:
In a crate, wire cage or dog pen
inside In
a kennel, outdoor, indoor or both Tied up Outside Dog will be loose inside Dog will be loose outside Other How will you exercise the dog?
Leash walks everyday Will have cable or dog run in yard Free to run inside fenced yard Will have supervised
access to unfenced yard Will
be free to roam around (unleased/unsupervised) Will take to dog park (public area where dogs run off leash and play together) Other Is your home in the:
Suburbs Rural area City/Urban area Size of Yard:
Small Medium Large Acreage No
yard Is the yard enclosed by a fence?
Yes No No yard If so, height, length and type of fence
(privacy, chain link, farm fence, invisible fence, etc.) Do you live in a house or apartment? Do you own the property?
Yes No If you are renting, please provide landlord'
name and telephone number for verification Does your municipality have breed specific legislation?
Yes No Don't Know Do you have other dogs? (Check all that apply)
No Other Dogs One or more spayed female One or more neutered male One or more UNspayed female One or more UNneutered male Please specify breeds and ages of other
dogs If you had other dogs in the past, please advise of
their current disposition:
Still have the dog Died of old age/fatal disease Gave away or sold to friend, relative,
acquaintance Was hit
by car Stolen Disappeared/Lost Poisoned Please specify what happened What other kinds of animals do you own? Are your other pets on any type of heartworm prevention?
If so, state the brand/type. Of all the breeds available, why do you
want to adopt a pit bull? Do you have any experience with the breed?
If so, please describe: Name and telephone number of your vet? Does your vet have emergency hours? If
so, please list. Does everyone in your household want this dog? Who will be the primary caretaker of the dog? Does anyone in your household have allergies?
If so, please specify. Are you willing to work with this dog on any issues
he/she may have? Excluding your death and severe aggression,
what would cause you to return this animal to rescue? May we visit your home before and/or after the adoption?
Yes No What is the best time to call to discuss and/or get
an update on the dog? REFERENCES: Please provide: (1) Name
(2) Telephone Number (3) E-mail Address (4) Relationship and (5) length of time known for 2 individuals who can verify your
ability to care for this animal. Additional information you would like
to provide about yourself and/or the dog you would like to adopt: * By checking YES you agree that the dog will not be
used in any illegal activities nor be found at any time in a municipality where Pit Bull presence is illegal.
Yes No * By checking YES you agree that the dog is to be
kept as a house pet. It shall not be sold for medical or experimental purpose, and it shall not be used for breeding.
Yes No * By checking YES you agree to absolve BLESS THE BULLYS
and all of its representatives from any liability in reference to a dog featured in this web site
Yes No
