Name(s):

Home phone:

Work phone:

Email address:

Occupation(s):

Home address:

City:

State:

Zip:

Mailing address (if different):

How long have you been at this address?

years and months

Do you  own or  rent?

Do you have the permission of your landlord to have a dog?
Yes     No

If Yes, up to what size?

Are you interested in a particular dog?

Yes

If Yes, which one?

In the event that dog is not available, please list your 2nd choice:

Please list your 3rd choice:

No

If No, what breed/size are your interested in?

Gender preferred Either Female Male

Age desired: Specific (please specify ->) Any Baby Young Adult Senior    

Specific age:

Will you accept a Mix? Yes     No

Would you consider a Special-Needs Rescue Animal such as one who requires medication for a permanent but controlled condition?

Yes     No

Please tell us why you want a Dog:

Please tell us a little about your lifestyle, your family, including
any special activities in which your dog would be included. (If you
have any special requirements or requests for a dog, please let us
know so that we can more carefully match a dog to your lifestyle.):

Do you have any children, currently expecting a child or planning for a child?
(Please note: SCMR policy is that we do not adopt to households with children 10 or under.)

Have child(ren)   Age(s):
Currently expecting a child
Planning for a child
No children
Not currently expecting a child
Not planning for a child

Please let us know who else lives in your home, their age,
and do they share your interest in adopting a dog?

Who is the dog primarily for? Adult Child Elderly Physically challanged

Who will care for, train and exercise the dog?

Does anyone in your household have allergies to dogs?

Yes     No

May we visit your home prior to application approval?

Yes   When?
No

Please list all the pets you have owned, what kind, sex, spay/neutered, and what happened to the pet.

Do you currently have other animals? Yes     No

If yes, please list type of animal, age, and sex:


Have they ever been around other animals?

Yes     No

Do they get along with other animals?

Yes     No

Do your pets have any characteristics that we should be aware of that would affect an animal coming into the home (i.e., is your pet aggressive toward other animals, etc.)?

Yes

Please describe the characteristic(s):

No

Where will the dog be during the day?

Will someone be home during the day?    Yes     No

How many hours will this pet be alone during the day?

Where will the dog be at night?

Is your yard fenced in?
(SCMR does not adopt to homes with Electric Fences*)

Yes

If Yes, what type and height?
    

No

If No, please describe how you plan to confine your dog to your property when outside:
    

Do you have a swimming pool? Yes     No

If Yes, do animals have free access to it?

Yes     No

Are you willing to obtain a crate and crate-train your dog if necessary?

Yes     No

Where will the dog stay when you are on vacation or out-of-town?

If you move, what will you do with your dog?

What behaviors would cause you to give up your dog?

Do you have a current or previous vet? Yes    No

Please provide the name of your current (or previous, if no current) veterinarian and the full name, address, and phone number of his/her
vet clinic:

  Vet name: 

  Clinic name: 

  Street address: 

  City:       State: 

  Phone: 

May we contact your vet for a reference? Yes     No

We also request you contact your veterinarian's office to let them know SCMR will be calling, giving them permission to talk to us at that time.

Please provide the full names, addresses, and phone numbers of 3 personal references that are not relatives:

Reference #1:

Name(s):

Address:

Contact Number(s):

How do you know them?

Reference #2:

Name(s):

Address:

Contact Number(s):

How do you know them?

Reference #3:

Name(s):

Address:

Contact Number(s):

How do you know them?

If you do adopt a rescue dog and decide to give it up, do you agree
to contact us and make arrangements to get the dog back to SCMR?

Yes     No

Have you or any members of your family/household been cited for
leash law violations or cruelty to animals in the past?

Yes    

If Yes, please specify:

No

Have you applied to any other Rescue groups?

Yes     No

If yes, please identify the group so that we do not duplicate their efforts:

I/We attest that the Terms and Conditions of Adoption as stated below have
been read in full by me/us and I/we understand that is part of the adoption
process and will be enforced.

  I/We attest that the information provided on this application is true and accurate to the best of my/our knowledge.

  I/We attest that we have retained a copy of the Terms and Conditions of Adoption and also understand that completion and submission of this application does not guarantee adoption of a Rescue Animal.

  I/We understand that any misrepresentation of fact may result in the removal of the adopted dog from my/our home.

  I/We understand that if this application was submitted via email, formal signature(s) will be obtained when and if adoption takes place.

Yes     No

Applicant's signature: __________________________

    Date: _______________

Co-applicant's signature: __________________________

    Date: _______________

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If submitting this application online, please click on the button below. A signature is not required.

This Agreement may be executed in one or more counterparts, each of which will be deemed to be an original copy of this Agreement and all of which, when taken together, will be deemed to constitute one and the same Agreement. The exchange of copies of this Agreement and of signature pages by facsimile or other electronic transmission shall constitute effective execution and delivery of this Agreement and may be used in lieu of the original Agreement for all purposes. Signatures of the parties transmitted by facsimile or other electronic transmission shall be deemed to be their original signatures for all purposes.

If you prefer to submit via snail mail, please sign and send to:

SCMR
P.O. Box 2005
Chattanooga, TN 37409

(updated: 10/23/09)