Aussie Rescue & Placement Helpline

Personal Information

Salutation: Mr. Mrs. Ms. Mr. & Mrs. Dr. Prof.
First Name:
Last Name:
Other Family First Names:
Email Address:
Occupation:
Name of Employer:

Address Information

Street Address:
City:
State: Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota North West Territory Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Is. Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:

Dog(s) in which you are most interested:

Phone Numbers

Home Phone:
Work Phone:
Cell Phone:
Fax:
Best time to call:

Reference Information

Personal Reference:
Relationship:
Reference Phone Number:

Home Environment Information

Do you live in a: House Apartment Condo Townhouse Mobile Home
Do you own or rent: Own Rent Neither
If you rent, do you have your landlord's written permission to have a dog on the property?:
Landlord Name:
Landlord Phone:
How long have you lived at this address?:
If less than one year, provide previous address:
Do you have a fence? Yes No Will have one installed
Describe the height and type of the fence:
If no fence, how will you handle the dog's exercise and toilet needs?
How many adults are in the household?
How many children are in the household?
What are the ages of the children?
Is anyone allergic to dogs or dog hair?: Yes No I Don't Know

Animal Ownership Information

Have you ever been cited by Animal Control? Yes No
Have you ever owned a dog?: Yes No
Have you ever owned a rescue dog? Yes No
What breed is/was the rescued dog?
How was the rescued dog obtained?
Provide a history of each dog ever owned:
What animals are currently in your household?
(List pet / breed / sex / age)
What is the name of your current vet?
What is the name of the vet clinic?
What is your vet's phone number?
Where will your dog spend the day?
Where will your dog spend the night?
On average, how many hours a day will the dog be left alone?
Have you owned a Herding Breed before? Yes No
Will you enroll the dog in obedience training? Yes No Maybe If necessary If required
We suggest you look at both males and females as each dog is unique. Either will make an excellent pet. Do you prefer a male, female or have no preference? Male Female No preference
Please list the dog that you are interested in and your age preference for the dog you would like to adopt.

This will assist the Adoption Consultant in helping you find the dog which is right for you.

Comments, Age(s) Preferred:

I am willing to let an ARPH-GA representative visit my home.

Applicant agrees to the following:

I understand there may be an Adoption Fee in order to help cover expenses incurred and that this fee is unique to each dog and situation. Should an unaltered male or female dog be placed with me, I agree to have the dog Neutered or Spayed by such date which is agreed to by myself and the dog's guardian. All of the information I have given in this Adoption Application Form is true and complete. Submission of this application constitutes my permission for the Rescue Organization to check references and my agreement with the terms of this Adoption Application Form.