Bell's Promise Animal Rescue Adoption Application
Please use this form to submit your request to adopt one of our rescued animals!
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Email *
Phone number *
Full Name
Address *
City & State *
Pet Name & ID Number *
Zip code *
Emergency Contact Information
Please list the people who live in your household by name, age, and relation:
Do you have physical limitations or health issues that would keep you from exercising your dog: *
Do you own or rent your residence? Is it a house? Apartment? Condo? Duplex? Please describe your residence. *
How long have you resided at this location?
If renting, do you have landlord’s permission to have a dog?
Is there a size/weight limitation on the type of dog you can have? If so what is the limit?
Landlord's name and phone number for verification:
Do you have a pet now? How many? What kind? Please list all pets, breed, ages, sex below:
Veterinarian Name & Phone Number
Do your animals get along with other dogs?
Have you ever had multiple dogs in your home? Explain...
Is there anybody home during the day? If yes, who?
How many hours a day will the dog be inside?
How many hours a day will the dog be outside? *
About how many hours will the dog be left alone? *
Where will the dog stay when he/she is home alone? (please be as specific as possible; i.e. run of the house, a specific room, a crate, etc.) *
Where will the dog sleep at night? Doghouse, garage, kitchen, living room, master bedroom, spare room, bathroom, laundry room, run of the house, other? *
What outside areas are available to the dog? Garage? Fenced Yard? Enclosed Patio? Doghouse? Unfenced area? If other, please specify. *
Type of fencing? (Chain link, wood, block wall, etc.) Height of fence? Is the fence in good condition?
Is the fence intact on all sides and is at least 6 feet from the ground level in all areas? Please describe any areas that are not.
I promise to inspect my fences thoroughly before the home visit and make necessary repairs for the safety and well being of our new Pet: *
Do you have a swimming pool? If yes, is the swimming pool surrounded by a gate?
Who has access to your yard? Family? Friends? Pool man? Gardeners? Utility company? Anyone else? Please explain: *
How would you socialize your dog? Dog parks? Dog walks? Play dates? Play with other dogs at home? Explain:
When you go on vacation, who will care for the dog? Friend? Kennel? Dog-sitter? Please explain:
Do you have a regular vet? Please provide the name and telephone number of your vet. Do you need a referral to a vet?
Pets are an investment of your time and money. Can you afford to provide medical care, grooming, proper diet, shelter, and exercise for your new pet?
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I understand that a home visit is required prior to final placement: Yes or no *
I understand that a home visit does not guarantee placement: Yes or no *
Bell's Promise Animal Rescue reserves the right to refuse adoption to any applicant for any reason. This questionnaire becomes part of our contract. No field should be left blank. Please respond in some way to every question on the application form.

• I understand that I am entering into a binding contract with Bell’s Promise Animal
Rescue Inc. 501c3 for the adoption of the above rescued animal. I have read this entire
contract CAREFULLY before signing it.

• I agree that the above animal is being adopted as a family pet. He/she will have extensive
house privileges, will sleep indoors, and WILL NOT be kept primarily in the yard or

• The above animal WILL NOT be kept on a chain.

• I agree to provide the above animal with proper food, water, and shelter.

• I agree to provide the above animal with all necessary vet care and treatment.

• I agree to provide the above animal with MONTHLY Heartworm prevention, as well as
flea and tick preventative.

• If I can no longer keep the above animal, I will notify Bell’s Promise Animal Rescue Inc.
501c3 IMMEDIATELY, so the rescue can reclaim the pet as soon as we can arrange transport and a place for the dog. I understand that under NO CIRCUMSTANCES will I give the animal to a third party or take the pet to a shelter.

• I fully understand and acknowledge that Bell’s Promise Animal Rescue Inc. 501c3 IS
NOT RESPONSIBLE for any injury (human or animal), damage or harm cause by the
above animal. I hereby release Bell’s Promise Animal Rescue Inc. 501c3, and its
representatives, from all liability and financial responsibility from any injury (human or
animal), damage, expense or liability I may incur, relating to the above animal. I agree to
not hold Bell’s Promise Animal Rescue Inc. 501c3 liable from ANY AND ALL such claims
and to pay, without limitation, any costs related to such injury, damage, or liability,
including, in the case of litigation, any attorney’s fees incurred by Bell’s Promise Animal
Rescue Inc. 501c3 in their defense.

• I agree that Bell’s Promise Animal Rescue Inc. 501c3 may make visits at a mutually
convenient time to ascertain that all of the above conditions are being satisfied. If any
representative from Bell’s Promise Animal Rescue Inc. 501c3 contacts me to inquire
about the animal, I agree to make a good faith effort to return their call as soon as
possible. I understand that Bell’s Promise Animal Rescue Inc. 501c3 may reclaim the
above animal at ANY time if, in their opinion, any of the agreed upon conditions are not
being met or they feel that the above animal is not being cared for properly.

• The above animal has been examined by Bell’s Promise Animal Rescue Inc. 501c3 and a
veterinarian prior to adoption and has received all necessary immunizations. However, I
understand Bell’s Promise Animal Rescue Inc. 501c3 does not hold representations or
warranties regarding the animal’s health, physical condition, or age. I understand that
veterinary problems may arise with this animal, and that those problems are solely my
responsibility, as are all related costs once I have adopted the above animal.

• I agree to provide the above animal with proper veterinary care in a timely manner.

• I agree that Bell’s Promise Animal Rescue Inc. 501c3 has informed me of ALL known health and behavior issues and/or problems that the above animal may have. I agree that Bell’s Promise Animal Rescue Inc. 501c3 has informed me of veterinarian’s and shelter staff’s best estimate of the above animal’s age and history

• I understand that the adoption fee for the above animal is NONREFUNDABLE for ANY

• I agree to abide by the adoption conditions and realize that I am committed to the above
animal for the remainder of his/her life.

By signing and sending this electronically, I acknowledge that I have completely read this contract and comprehend it fully.  Please sign your name below. *
A copy of your responses will be emailed to the address you provided.
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