Adoption Application Fields Marked with * are required To ensure that prospective owners are serious about their adoption, a $25.00 (non-refundable) adoption application fee is charged. (Or you may pay with a debit card using Stripe $26.25, under the Donate link, and state that it is for the application fee) Once an application is submitted, the fee should be sent to Heartland within three days. This fee will be applied against the adoption fee. Contact Information Name of Applicant (Dog’s Primary Caregiver)* Co-Applicant (if applicable) Mailing Address* Address 2 Street Address (if different from mailing): City* State* ZIP/Postcode * Primary Phone * Work Phone Email * Family Information If you have any children under the age of 18, please give their ages: If you have children under 8, please read our policy. Do they live with you or visit you? Live WithVisit If there are there other occupants in the house, do they share in your desire to adopt a Golden? YesNo Does anyone in the household have allergies?* YesNo Are the allergies animal related? YesNo Dog Preferences How did you find out about us?* Have you owned a Golden in the past?* YesNo Have you applied to another group for a Golden?* YesNo If you have applied to another group, please provide the name and the date of application May our representative visit you at your home prior to adoption?* YesNo Are you willing to consider a dog with special needs?* YesNo A dog that is deaf or blind? YesNo What age dog are you interested in adopting?* 0-6 Years7-8 Years9+ yearsAny Age What activity level would you prefer?* HighMediumLow Would you consider adopting a Golden mix or x-breed?* YesNo Sexual Preference* MaleFemaleDoesn't Matter Pet Care Questions How long have you lived at your current address?* Do you own or rent?* OwnRent (If you rent, please provide your landlord’s name, address, and phone number) Do you have your landlord’s permission to have a large dog at your residence? YesNoN/A Please identify all veterinarians used over the past five years (including name, address, and phone number)* Please list all the pets you have owned in the past three years and include: species, sex of pet, whether spayed or neutered, if not altered, please explain: Are these pet(s) still alive? YesNo Have any of your pets ever been treated for heartworm? YesNo If yes, please explain the circumstances Please list two references including their names, addresses, and phone numbers (Only one can be a relative. You cannot use a vet as a personal reference.)* We reserve the right to call your landlord (if one is renting). May we have your permission to check your veterinarian and personal references?* YesNo If yes, please notify your veterinarian that we may call and that you give your permission for us to check on the past care of your animals Are you familiar with the use of a dog crate to train and/or confine the dog in your absence or at night?* YesNo Are you willing to use a crate (if needed)?* YesNo How long will your dog be left along during the day?* Where will the dog be kept during the day?* Where will the dog be kept during the night?* Is there anyone home during the day?* YesNo Is your yard fenced?* YesNo If fenced, type and height of fencing? What is the size of the dog’s yard area? Will the dog be walked daily?* YesNo Allowed to run free off your property?* YesNo Will your dog be in the house?* YesNo Will your dog have the run of the house?* YesNo Be tied outside?* YesNo Live in the yard?* YesNo Will your dog receive formal obedience training?* YesNo Have you ever trained a dog before?* YesNo Are you aware that Goldens shed all year long?* YesNo Are you aware that routine costs of maintaining a dog can easily average $1000.00 per year?* YesNo Will you groom your Golden or use a groomer?* SelfGroomer In the event you are unable to care for this pet in the future, who will accept responsibility for its care for the balance of its life?* Will you notify a golden rescue organization if this should occur?* YesNo Have you sold, given away, or surrendered a pet to a shelter or rescue in the past?* YesNo If yes, please give an explanation: Please tell us why you want a Golden Retriever?* What type of activities will your dog and you enjoy together?* If you move, what will you do with the dog?* Are you willing to take responsibility of this dog for 10 years or more of its life?* YesNo Have you read our Adoption Procedure?* YesNo Have you read our contract? YesNo Important: If you get an error when submitting this form, please email us at email@example.com, as there is a chance that the form was recorded in the database and we can pull it from there. [recaptcha] To ensure that prospective owners are serious about their adoption, a $25.00 (non-refundable) adoption application fee is charged. (Or you may pay with a credit/debit card using Stripe $26.25, and state that it is for the application fee) Once an application is submitted, the fee should be sent to Heartland within three days. This fee will be applied against the adoption fee.