Name of applicant (Dog's Primary Caregiver)

Co-Applicant

Mailing Address:

Street Address (if different from above):

City:   State:   Zip:

Home phone:     Work phone:      Cell phone:

Best time to contact:     Email:

Do you have any children (under 18years old)? Yes   NoIf yes, please give their ages

Do they live with you or visit you?    Other family members or co-inhabitants

Do they share in your desire to adopt a Golden? Yes No   Does anyone in your household have allergies?  Yes No

Are they animal related?  Yes   No:

How did you find us? Past Adopter Veterinarian   Shelter/Humane Society  Internet Other - please explain

  Have you owned a Golden before?  YesNo  Have you applied to another group for a Golden? Yes   No   If yes, which group(s) and date of application   May we (or our representative) visit you at your home, prior to adoption?  Yes  No  Would you consider a special needs dog (i.e. one who requires medication for a permanent but controlled condition i.e. seizures, or one who is blind or deaf for example)? Yes   No   What age are you interested in adopting? Any age   Specific age - please give age    Senior (8years and older?   Activity level: High   Medium   Low     Sex: Male  Female Either

How long have you lived at your current address?   Do you:  Own   Rent If you rent, please provide your landlord's name, address and phone number below***: 

Landlord's Name and Address   Landlord's phone #   Do you have your landlord's permission to have a large  dog?  Yes   No

Please identify all veterinarians used over the past five years (please include their name, address and phone number)***

Please all pets you have owned in the past three years and include: species, sex of pet; whether spayed or neutered - if not altered, please explain; is pet(s) still alove?   Have any of your pets ever been treated for heartworms? Yes   No   If yes please explain circumstances Are all dogs, currently living with you on regular heartworm preventative?  Please list type of medication; how often given; if not on preventative, please explain why   Please list two references, one of whom must be a non-family member. (please include their name, address and phone number)  We reserve the right to call your landlord; do we have your permission to check your vet reference(s) as well as your personal references ***  Yes   No  Please notify your vet(s) 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?  Yes No   Are you willing to use a crate  Yes   No   How long will your dog be left alone during the day?   Where will pet be kept during the day?  Please be specific   Where will pet be kept at night?   Is there anyone home during the day?  Yes   No    Is your yard fenced?  Yes No   Type (chainlink, hidden, wooden) and height of fence   If you do not have a fence, will you install one?  Yes   No   Size of do's yard area?    Will the dog be walked daily?  Yes   No   Exercised in a fenced yard? Yes   No   Allow to run free? (Off your property) Yes   No Will your Golden be allowed in the house?  Yes   No   Will your dog have the rung of the house: be in blocked-off parts of the house: be tied outside; or live in the yard?  Please be specific   Will your dog receive formal obedience training? Yes No   Have you ever trained a dog before? Yes   No   Are your aware that Goldens shed all year long? Yes   No   Will you groom your Golden or use a groomer?   Are you aware that routine costs of maintaining a dog can average or $1,000 per year?  Yes   No

 In the event you are unable to care for this pet in the future, who will accept responsibility for its care for the balance or its life?   Will rescue be notified?  Yes   No   Have your sold, given away, or surrendered a pet to a shelter or rescue?  Yes   No   If yes, please explain   Please tell us why you want a Golden   What type of activities will you and your Golden enjoy together?    If you move, what will you do with this pet?   Are you will to take responsibility of this pet for 10 years or more of its life?   Yes No   Please feel free to add any other information that you think might be helpful to us in evaluating your application  Have you read, and understood our Adoption Procedure, Golden Facts and Adoption Contract  Yes No  

 

 

Thank you for taking the time to fill out our application, and for your interest in our program.   To ensure that prospective owners are serious about their adoption, a $25.00 adoption application fee is charged. This fee is non-refundable but will be applied against the adoption fee if the application is approved.Please send to:-

Heartland GRR, c/o Susanne Simon, 3 Old Coach Circle, Hampden, MA 01036

Your application will not be processed until we receive this fee.

We will respond to your application as soon as possible; please remember that this organization is staffed totally by volunteers!

**Submission of Application DOES NOT guarantee adoption of a dog from
Heartland Golden Retriever Rescue**