First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

Email*

Home Phone

Cell Phone

Text/Pager Email

Which animal are you interested in
Sorry, no animals found

Are you at least 18 years of age?

What is your housing situation?

If renting or living in a mobile home, please list landlord's or lot owner's name and phone number.

Is your yard fenced*
Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

Are there any other pets at home?

If yes, please list their breeds and ages.*

Are your other pets spayed or neutered?

If not, why?

Will your dog be an "outside" dog who will sleep outside and spend most or all of his/her time outside?

Please list the name, phone number, and address of a personal reference.*

Veterinarian's Name and Phone Number*

I certify that the information entered on this applicant is true. Enter your name and date*

Do you give permission for the release of any information requested by Rockbridge Dog Rescue regarding care and past care of your pets?