NCCR Adoption Application Form
Please complete entire application.
Name of dog that you are interested in:
Your answer
When would you would be ready to take the dog/puppy home?
Your answer
I would prefer:
Breed/mix preference?:
Your answer
Size when full grown?
Male/female?
Your answer
Energy level?
Your answer
Housetrained required or willing to train?
Your answer
Your name:
Your answer
Date of birth:
Your answer
Are you:
Street address:
Your answer
Town, State and zipcode
Your answer
Telephone # and Work #:
Your answer
Email address:
Your answer
Maximum number of hours pet will be alone daily:
Your answer
Name of each adult in your home:
Your answer
Age(s) of children in the home:
Your answer
Age(s) of children that visit frequently:
Your answer
Have children been around dogs before?
Why do you want to adopt a dog?
How many pets have you had in the last 10 years?
Your answer
Type of pet and pet's name
Your answer
Age of pet and if spayed/neutered
Your answer
How long have (did you have) pet?
Your answer
If you no longer have pet, why not?
Your answer
Type of pet and pet's name
Your answer
Age of pet and if spayed/neutered
Your answer
How long have (did you have) pet?
Your answer
If you no longer have pet, why not?
Your answer
Type of pet and pet's name
Your answer
Age of pet and if spayed/neutered
Your answer
How long have (did you have) pet?
Your answer
If you no longer have pet, why not?
Your answer
List additional pets and their information.
Your answer
Provide your vet's name and phone number. Please call your vet to give your permission to release information to the NCCR adoption counselor. We are unable to complete processing your application if we are unable to speak with your veterinarian.
Your answer
Are your pets kept inside or outside?
Your answer
Where are your pets kept when you are not home?
Does anyone in your home have allergies to dogs?
Your answer
Do you rent or own? If you rent, you must provide landlord's name and phone number.
Your answer
Is your yard fenced? And if so, what type of fence?
Your answer
Are you able to leash walk your dog?
Your answer
How will you correct inappropriate behavior?
Your answer
How will you "housebreak" your dog if he/she is not housebroken?
Your answer
Have you ever given a dog or puppy away?
If you have given your pet away, please provide details.
Your answer
Have you ever had an animal taken away from you by dog control or animal control?
Have you ever applied for a dog from NCCR before?
Have you ever adopted a dog from NCCR before?
Could we arrange a time for a home visit?
List three (3) references along including phone numbers where references can be reached in the evening. If we are unable to reach your references, we will be unable to complete the processing of your application. Your references must include at least one neighbor and a co-worker or friend.
Your answer
Please list any behavior problems you could not tolerate:
Your answer
Please tell us anything you would like us to know about your family or the ideal dog that you are looking for.
Your answer
Where did you hear about Northern Chautauqua Canine Rescue?
Signature and date:
Your answer
Your answer
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