Dogs Name:

________________

APPLICATION FOR ADOPTION

Rescue Name:
________________

Adoptees Name: _____________________________________

Address: ______________________ City/State: ____________________ ZIP Code: ___________
Phone:

Cell: ___________________

Work: ___________________

Home: _________________Spouse: __________________

E-Mail: _________________________________ Spouse: ___________________________________

HOME:
Own Home
Rent.HOME.or APARTMENT (circle one)
YES NO
If you RENT: Landlord name and phone #:
_________________________________________
Does your home have a fenced yard?
BOTH

YES

NO

Do you have to pay a pet deposit?

If Yes: FRONT

BACK

If yes, what kind:

Chain Link (how tall) ____________
Privacy Fence
Other: (Explain/describe)
_______________________________________

OTHER PEOPLE LIVING IN YOUR HOUSE:

Please list all members of the family/those living in your household:
Name: ________________________ Relationship ________________ Age ______________
Name: ________________________ Relationship ________________ Age ______________
Name: ________________________ Relationship ________________ Age ______________
Name: ________________________ Relationship ________________ Age ______________

OTHER DOGS LIVING WITH YOU:

NAME

TYPE/BREED

AGE

NEUTERED/SP
AYED
YES
NO
YES
NO
YES
NO
YES
NO

OTHER PETS LIVING WITH YOU:

NAME

TYPE (Cat/Bird/etc)

AGE

NEUTERED/SP
AYED
(IF applicable)
YES
NO
YES
NO
YES
NO
YES
NO

VETERINARIAN YOU USE:

Name: ____________________________ Phone #: ___________________________
Are all of your cats & dogs up-to-date on their vaccinations?

YES

NO

SOME

ACCOMMODATIONS:
Where will the dog stay during the day?
Where will the dog stay at night? Inside

Inside Outside
Outside

If the dog goes Outside at any time, is there a shelter/dog house of some kind?
YES NO
Please describe: ______________________________________________________
If the dog stays INSIDE, what will you have for its comfort?
Crate

Stand-alone dog bed Separate Room Sleep on someones

bed
On the average, how many hours per day is the dog going to be left alone?
________________________

REFERENCES: Please supply 2 references that are not relatives:

1. NAME: _____________________ Phone: _____________________ RELATIONSHIP:
_________
2. NAME: _____________________ Phone: _____________________ RELATIONSHIP:
_________
If you have no Veterinarian Reference, please give an additional personal reference:
3. NAME: _____________________ Phone: _____________________ RELATIONSHIP:
_________

Do you want your dog(s) microchipped?

YES

NO

The company I use is SmartTag. The chip is FREE for the life of the pet but you
can buy into packages for greater benefits. Please look at the site idtag.com

ADOPTION AGREEMENT

Date: __________________

The following are the terms which you agreed for the adoption of the dog called
________________________.
I agree to take adult dogs to the vet within 30 days and puppies within 2 weeks of adoption to
continue heartworm & flea prevention and /or well care. ___________
I agree to foster dog if there is any reason dog is not adjusting well until dog can be rehomed and to
contact Ellen Dorfman immediately with this issue. ______
I agree to release rescue organization from liability for this animal's care and behavior once I
adopt.______
I agree that this is a rescue dog, and most likely a stray. Therefore I understand that the rescue has
no knowledge of dogs abilities beyond our experience with the dog in our foster homes. I also
understand that the dog comes with limited medical history.______
I agree to pay the adoption fee immediately unless other terms are agreed upon to appropriate
Paypal.________
If adopter cancels adoption and transport is in route, rescue will refund portion of adoption fee
-the transport fee which is determined by transport not rescue.____
If adopter cancels adoption within 24 hours prior to transport a fee of $100 will be retained by
rescue due to potential loss of qualified adopter. ____
Payment through PayPal must notate on the payment that it is for Dog Adoption (name of dog).
Transport will be arranged by Rescue and communication will be continued with Ellen Dorfman.
360-480-9531

____________________________
Name Printed

SIGNATURE: __________________________

____________________________
Phone #

DATE: ________________________________

What Pick-Up Location do you want to

use?
___ Sacramento, CA
Dorfman), WA
___ Eugene, OR

___ Olympia (Ellen

___ Federal Way, WA

If you do not get this dog/puppy, would you like us to keep you on an
e-mail list to receive the info about our most current dogs/puppies
that become available before they hit the internet?
____YES
____ NO

After adoption fee is received, the dog is considered adopted

and removed from the available pet list. It is imperative that
you make yourself available for Transport pick up the entire
weekend of transport, simply in case an emergency arises on
transport. Ellen Dorfman and Paws Without Borders work
tirelessly to make sure all issues are communicated including
traffic delays through their Facebook page during transport
and via Ellen. You must be at Pick Up location determined or
someone in your place and this information also needs to be
communicated to Ellen so she can relay appropriate
information to PWB.
Thank you for considering a rescue pet. We take the health
and wellbeing of our rescued dogs very seriously. We have
devoted our lives to saving these animals because we see
their value and the love these animals share. We focus, while
they are in our homes, on understanding their personalities
and quirks so we can find the best fit for both the dog and the
family. We ask that you remember no animal is perfect: the
transport in itself can be stressful for some so please
understand that your new pet may need time to adjust, both
physically and emotionally. Diarrhea, low appetite or
timidness are just a few of the signs your new pet may show.
Be patient, they will adjust.