First Name Last Name Street Address City State Zip Code Phone No. Alternate Phone No. E-mail Address Date of Birth Occupation Do you live with:
Spouse/Partner Roommate Parents Other How many adults (21 and over) live in your household? How many individuals under age 21 live in your household? What are the ages of individuals under 21 in house? How far can you travel to pick up dog? Name of dog you are interested in adopting: Do you prefer an adult or puppy? Prefer dog to be:
Already spayed/neutered Not spayed/neutered Doesn't matter Will the dog be:
indoor dog, living inside with family live in the basement or garage live outside guard dog for business or residence Other How many hours a day will dog be left alone? When home alone, the dog will be:
in a crate, wire pen or kennel
inside In
a kennell, indoor, outdoor or both Tied or chained outside loose inside the house loose outside the house Other How will dog get exercise?
leash walks everday cable or dog run in yard free to run inside fenced yard supervised access to unfenced
yard free to roam
outside dog park other Is your home in the:
Suburbs Rural area City/Urban area Do you have a yard? If yes, is yard enclosed by fence? Height, length and type of fence Do you live in a house or apartment? Do you own the property? If you rent, please list name and phone number of landlord
for verification Do you live in an area that pit bull ownership is regulated? Do you have other dogs?
No other dogs One or more spayed female One or more neutered male One or more UNspayed female One or more UNneutered male Please specify breeds and ages of other
dogs If you've had other dogs in the past, please describe
their disposition
Still have dog Died of old age/fatal disease Gave away or sold to friend, relative or aquaintance Was hit by car Stolen Disappeared/Lost Please describe what happened. What other kinds of animals do you have? Are your other pets on heartworm prevention? Of all the breeds, why do you want to
adopt a pit bull? Do you have any experience with the breed?
If so, please describe. Name and telephone number of your vet. Does your vet have emergency hours? If
so, please list. Does everyone in your household want to
add a pit bull to the family? Who will be the primary caregiver? Does anyone in your household have allergies?
If so, please specify. Are you willing to work with this dog
on any issues he/she may have? Is there anything that would cause you
to return this dog to rescue? Do you agree to a home visit should your application
be approved? What is the best time to contact you to discuss your
application? REERENCES. Please provide: (1) Name (2)
Telephone Number (3) E-mail Address (4) Relationship and (5) length of time known for 2 individuals who can verify your ability
to care for this animal. Additional information you would like
to provide about yourself and/or the dog you would like to adopt: * By checking YES you agree that the dog will not be
used in any illegal activities nor be found at any time in a municipality where Pit Bull presence is illegal.
Yes No * By checking YES you agree that the dog is to be kept
as a house pet. It shall not be sold for medical or experimental purpose, and it shall not be used for breeding.
Yes No * By checking YES you agree to absolve BLESS THE BULLYS
and all of its representatives from any liability in reference to a dog featured in this web site
Yes No
