Fax Number
Mailing Address
E-mail
Confirm e-mail
Would you be willing to adopt a Dog with special needs; i.e.Deaf,
Blind, older, needs surgery, needs medication, is , has behavioral
problems, never lived inside a house before,etc.?
Yes
No
Which dog or dogs of ours are you interested in?
Why do you want a Dog?
What other animals do you have?
Are they spayed/neutered and if not, why?
Please list any pets you have
owned?
Have you ever obedience trained (through classes) before?
Yes
No
Will you train your next dog through classes?
Yes
No
Does your lifestyle allow you to have the time and energy to properly
care for a Dog?
Yes
No
If you have previously owned a Dog, who did you purchase them
from and what became of them?
Have you or anyone in your immediate family ever been charged
with cruelty to animals or child abuse?
Yes
No
Are you going to be moving in the near future?
Yes
No
What will you do with your Dog should you have to move?
Occupation
Employer name & phone #
What are your work hours
Company Address
How long have you worked there
Are any other family members employed?
Yes
No
List their name, occupation, work hours and company they work
for:
How many adults are in your household, their names and how they
are related?
If children, list their ages & sex
Is anyone in your family home during the day?
Yes
No
Do you own or rent your home?
Own
Rent
Does your rental agreement permit you to keep pets?
Yes
No
How long have you lived there?
Landlord's name
Landlord's phone #
Do you have a fenced in area for your pets?
Yes
No
What kind/size of fencing?
If you have a pool, is it fenced in?
Yes
No
Not Applicable
Where will you keep your pet during the day?
At night?
When your family is away overnight?
When your family is on vacation?
What are the leash laws in your area?
Have you ever had a dog in the past that you kept chained or penned
outdoors?
What kind of vehicle(s) do you drive
Is at least one
vehicle large enough to hold a Dog of the size you are applying
to adopt comfortably in the cab?
Yes
No
Are
your pets on heartworm preventive?
Yes
No
What kind?
How often do you give it?
Date of last vaccinations
References:
Veterinarian's name
Phone #
Name and telephone number of 3 local individuals (not related)
who know/have known your other animals:
May we visit your home and check references to verify the information
you have provided?
Yes
No
How did you learn about Coda Dog Rescue.?
Signature of Applicant
Date
Return to:
C.O.D.A. Dog Rescue- (Cleveland Ohio Dog Advocates)
P.O. Box 44092
Brooklyn, Ohio 44144
Or submit through the internet using this page and form