NCCR Adoption Application Form
Please complete entire application.
Name of dog that you are interested in:
When would you would be ready to take the dog/puppy home?
I would prefer:
Breed/mix preference?:
Size when full grown?
Male/female?
Energy level?
Housetrained required or willing to train?
Your name: *
Date of birth: *
Are you:
Street address:
Town, State and zipcode
Telephone # and Work #:
Email address:
Maximum number of hours pet will be alone daily:
NAME(S) of each adult in your home: *
Age(s) of children in the home:
Age(s) of children that visit frequently:
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?
Type of pet and pet's name
Age of pet and if spayed/neutered
How long have (did you have) pet?
If you no longer have pet, why not?
Type of pet and pet's name
Age of pet and if spayed/neutered
How long have (did you have) pet?
If you no longer have pet, why not?
Type of pet and pet's name
Age of pet and if spayed/neutered
How long have (did you have) pet?
If you no longer have pet, why not?
List additional pets and their information.
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.
Are your pets kept inside or outside?
Where are your pets kept when you are not home?
Does anyone in your home have allergies to dogs?
Do you rent or own? If you rent, you must provide landlord's name and phone number.
Is your yard fenced? And if so, what type of fence?
Are you able to leash walk your dog?
How will you correct inappropriate behavior?
How will you "housebreak" your dog if he/she is not housebroken?
Have you ever given a dog or puppy away?
If you have given your pet away, please provide details.
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 including phone numbers where references can be reached in the evening. Please include the email address for your references whenever possible. If you do not provide references or 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. *
Please list any behavior problems you could not tolerate:
Please tell us anything you would like us to know about your family or the ideal dog that you are looking for.
Where did you hear about Northern Chautauqua Canine Rescue?
Signature and date:
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