Name

Street Address

City, State and Zip Code

Home Phone

E-mail Address

Date of Birth

Occupation

Do you live with

Spouse/Partner Roommate(s) Parents Alone

How many adults (21 and over) are in your household?

What are the ages of the individuals under 21 in your household?

Name of dog you are interested in adopting. (REQUIRED)

Dog's Living Situation

housepet, living inside with family Dog will live in basement or garage Dog will live outdoors Doghouse provided business or residence Other

How many hours a day will the dog be left alone?

When home alone, the dog will be:

inside or both Outside inside outside Other

How will you exercise the dog?

walks everyday in yard yard yard (unleased/unsupervised) area where dogs run off leash and play together) Other

Size of Yard:

Small Medium Large Acreage yard

Is the yard enclosed by a fence?

Yes No yard

If so, height, length and type of fence (privacy, chain link, farm fence, invisible fence, etc.)

Do you live in a house or apartment?

Do you own the property?

Yes No

If you are renting, please provide landlord's name and telephone number for verification

Do you have other dogs? (Check all that apply)

Dogs female male female male

Please specify breeds and ages of other dogs

If you had other dogs in the past, please advise of their current disposition:

dog disease acquaintance car Stolen Disappeared/Lost Poisoned

Please specify what happened

What other kinds of animals do you own?

Are your other pets on any type of heartworm prevention? If so, state the brand/type.

Of all the breeds available, why do you want to adopt a pit bull?

Do you have any experience with the breed? If so, please describe:

Name and telephone number of your vet?

Does your vet have emergency hours? If so, please list.

Does everyone in your household want this dog?

Who will be the primary caretaker of the dog?

Does anyone in your household have allergies? If so, please specify.

Are you willing to work with this dog on any issues he/she may have?

Excluding your death and severe aggression, what would cause you to return this animal to rescue?

May we visit your home before and/or after the adoption?

Yes No

What is the best time to call to discuss and/or get an update on the dog?

REFERENCES: Please provide: (1) Name (2) Telephone Number (3) E-mail Address (4) Relationship and (5) length of time known for 3 individuals who can verify your ability to care for this animal.

Additional information you would like to provide about yourself and/or the dog you would like to adopt:

* By checking YES you agree that the dog will not be used in any illegal activities nor be found at any time in a municipality where Pit Bull presence is illegal.

Yes No

* By checking YES you agree that the dog is to be kept as a house pet. It shall not be sold for medical or experimental purpose, and it shall not be used for breeding.

Yes No

* By checking YES you agree to absolve PIT MOUNTAIN and all of its representatives from any liability in reference to a dog featured in this web site

Yes No