Fill the Adoption Application Form Adoption Application Form Adopter's NameCo-Adopter's NameEmailPhone/MobileAddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePet NameWhich pet gender are you interested in? Male FemaleNumber of all permanent residents of your household (adults/children)*Do you currently have any pets?* Yes NoIf you currently have pets, please list them below. Are your current pets altered? Yes No Will be within the next 30 days, appointment has been scheduled. (We will call your vet to verify this.)If your current pets are not altered, please explain why below. Vet reference (please call your vet and give permission to release information to us)Two Personal ReferencesAre you planning to move in the near future? Yes NoIf moving soon, to what city/state? When will you be ready to pick up your pet if you get approved? This weekend Within a week Within a month Not ready yet, just researching OtherAre you in contact with any other adoption center about a specific pet? Yes, application is pending Yes, just an email inquiry, no app yet No, but I am looking at several dogs online No, I am only interested in this particular petAre you going to meet another pet? Yes NoIf so, when?Is anyone in your home allergic to pets? Yes NoDoes anyone in your home fear dogs? Yes NoDoes anyone in your home smoke? Yes NoAre you familiar with dog regulations in your area? Yes NoIf you answered no to the question above, please contact your town/county/condo assoc and ask them what the regulations are.If yes, please describe local pet regulations and restrictions: PreviousNextI/We live in a Single Family Home Duplex/Twin Condo/Townhome Trailer ApartmentDo you rent or own this property? Rent OwnRenters, have you contacted your landlord to find out if there's any restrictions on the kind or size of dog you can have? Yes No Not yet, but I will It's written in our leaseApproximate square footage of your home Less than 800 square feet 800-1,000 square feet 1,000-1,500 square feet 1,500-2,000 square feet Over 2,000 square feetDo you have a yard? Yard, fenced with a vertical fence Yard, fenced with invisible fencing Yard, no fence No yard (apartment/condo/townhome)If vertical fence, what is your fence height? 2' high 3' high 4' high 5' high 6' highApproximate dimensions of your lot:Annual Household Income Under $20,000 $20,000-$30,000 $30,001-$50,000 $50,001-$70,000 $70,001 or higherDo you work outside the home? Yes No One applicant is home/works from home We work different shiftsIf you both work outside the home, how many hours per day are you away? How many hours per day will this dog be alone? Please explain.Have you discussed this adoption with all members of your household? Yes No Yes, adults have discussed it. Kids don't know yet.PreviousNextBased on the description and the information you have gotten about the pet from our website/Facebook page, do you feel pretty confident that you will be likely to adopt this pet upon meeting it? Yes No Not sureUpon meeting the pet, what would give you cause to not want to adopt it? Please explain.How much do you feel you can reasonably afford and would be willing to spend on your pet per year (for things like veterinary care, licensing, ID tag, food, toys, crate, other supplies, training, pet sitting, etc)? What activity/energy level do you prefer? Wild and crazy is cool Leash trained daily jogging partner would be excellent Medium energy, plays a bit then hangs out with you Low energy, walks slowly on leash, a total couch potato OtherPreviousNextPlease check all that apply. I want to adopt this pet...As a family petTo breed with my dogTo use for researchTo train/use as a therapy petFor a jogging/hiking partnerTo interact with lots of friends/familyAs a gift for a friend, partner, or family memberAs a companion for my dog(s)As a companion for my cat(s)As a companion for my child/childrenPlease check all that apply. My adopted pet will... Be kept outside most of the timeBe kept indoors most of the timeBe left outside during the work day while we are awayBe kept inside while we are awayBe crated when we are not homeHave free reign of the house when we are not homeBe taken to formal obedience classesBe trained by me/usTake frequent car rides with usBe kept on a lead line/cable in the yardBe mostly interacting with adultsBe interacting frequently with children under 8Be interacting frequently with older childrenMust be housebroken prior to adoptionWill be housetrained by usWill be walked more than one mile per day every dayWill be walked occasionallyBe attending formal group obedience classes with usBe trained by us without the advice of a trainerHave private sessions with a trainer as neededBe attending agility classesBe taking frequent car rides/trips with usBe boarded when we go on vacationStay with family when we go on vacationBe given away to someone else if we feel it's not a good match for usBe turned in to a shelter if we can't keep itBe going camping with usBe going on boat trips with usBe outside with a pet house in a fenced areaBe free roaming on the farm (unfenced)OthersPlease take time to think, be honest with yourself and us when answering this question. What are you absolutely NOT willing to deal with at the time of adoption or at any time during the life of the pet?HousebreakingChewingJumpingPulling on leash during walksCounter surfingObedience trainingFear of menFear of womenFear of childrenMouthiness (may sometimes snag your hand or arm instead of the toy in play and will need redirection/training)GrowlingBarkingRough play with my petHigh activity levelFood/toy aggression/not willing to share with other dogsFood/toy aggression with peopleWhining/cryingCounter surfingBlindnessLimited SightDeafnessSeparation AnxietyDiabetesSpecial DietLong Term MedicationIncontinence / Leaking UrineTaking classes with the petGets stressed/carsick when riding in vehicleDoesn't know how to climb stairsCan't climb stairs due to age/arthritis/health issuesHeart conditionSkin allergiesFood allergiesTrimming nailsYeast on coat or in earsEar mitesFleasTicksHeartworm preventativeAnnual heartworm/lyme combo testingI will do whatever it takes to help this dog adjust and work with a trainer to help resolve any training needs.OtherWhat would cause you to return a pet?What do you feel is a reasonable amount of time for a pet to adjust to life with you/your family?How do you plan to integrate this pet into your family?What would you do if you discovered after adoption (at any time during the life of the pet) if your vet diagnosed an expensive health condition?PreviousFinal StepDo you plan to get pet health insurance? Yes No I wasn't aware this was available. I will look into itWhat brand of pet food do you plan to feed?Grooming (please check all that apply)We use a professional groomerWe trim dog nails ourselves at homeWe bathe our dogs at home once a weekWe bathe our dogs at home once a monthWe bathe our dogs at home once every few months or whenever their coat feels dirtyWe bathe our dog twice a yearWe don't bathe our dogWe check ears weekly for infection/yeast/mitesWe check coat daily for ticks in spring/summer/fallWe clean teeth using home methodsWe take our dogs to the vet for dentals whenever the vet recommends this is neededPrefer a dog that doesn't shedDon't care about sheddingHow long have you been looking for a pet?Do you plan to take formal obedience classes? Yes NoAdditional reference (if desired) Do you have any additional comments, questions or concerns? Anything else you would like us to know to help match you up to a pet?I understand that completing this application does not actually guarantee I will be allowed to adopt a pet, and that the application is a tool to help Bingo Sanctuary determine if this puppy and my family are a good fit for each other. I acknowledge that all information provided on this form is true and correct. I understand that any misrepresentations may result in my not being approved and/or removal of the adopted pet from my possession. I also certify that I have never been convicted of animal cruelty or neglect. I agree to allow a representative of Bingo Sanctuary to contact my vet for a reference and also agree to allow a home visit prior to adopting this pet. If I am approved to adopt a pet, I agree to pay a partially refundable reservation fee for paperwork completion and hand sign an adoption contract at the time of adoption/visit. The rest of the adoption fee is paid prior to pick up. I understand that all pets adopted from Bingo Sanctuary will be spayed/neutered, heartworm tested, fecal tested, and vaccinated prior to adoption. Please read the above, check this box, sign, and click Submit. I/We have read and understand all of the above.Date / TimeNote: After you submit this form, it will take you back to the Bingo Sanctuary home page. Feel free to write us with any questions: Contact us [email protected] Renters: Please send a copy of the pet section of your lease or a landlord pet permission letter to the email address above. Bingo Sanctuary have the right to reject any application based on information obtained during this screening process. Please understand that our primary goal is the health, happiness, and safety of our pets. Previous Submit Your Application
