Dog Application Step 1 of 4 0% Please review the BARC dog adoption policies here.Date:* Date Format: MM slash DD slash YYYY Age of dog desired:Please enter a number from 0 to 20.Name of dog desired, if known:Youngest dog considered:Please enter a number from 0 to 20.Oldest dog considered:Please enter a number from 0 to 20.Applicant InformationName:* First Last Suffix Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone Numbers:HomeWorkCell Email:* Enter Email Confirm Email Number of People in Household:If children are in the household, please list ages (separate by commas):Are you or any member of your family allergic to pets?YesNoAre you presently: Employed Unemployed Retired Student Employer: General InformationType of residence: House Apartment Townhome Condo Mobile Home Farm Do you own or rent?OwnRentAre you planning on moving in the next 6 months?YesNoIf yes, please note type of residence and location:If rental, are dogs allowed?YesNoMaybeSize Restrictions?YesNoIf yes, Max. size:Complex Name:Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Manager/Landlord: First Last Phone Number:Type of street: Very busy road Moderate traffic Slight traffic Speed limit:Where will dog live? Inside Only Outside Only Both If both, what percentage?Inside (%)Outside (%) Where will the dog spend nights? Family Member's Bed Dog Bed Garage Outside Other Do you have a fenced yard?YesNoWhat type of fence & how high?Will you allow the dog to run loose?YesNoIf yes, where?What is the approx. size of your yard?Do you have an invisible fence?YesNoDo you have a doggie door?YesNoHow many hours a day will the dog be alone?Please enter a number from 0 to 24.Where will the dog stay while the family is away from home (including short errands)?Describe the activity level in your home:Busy (visits by friends, meetings, children, parties at home)Noisy (Stereo/TV, tools, children playing, dogs barking)Moderate (Normal comings and goings)Quiet (homebodies, few guests)OtherIf other, please specify:Under what circumstance would you return the dog?In the absence of the primary caregiver, who will care for the dog? This may include going on vacations, being in the hospital, etc.Would you mind if a representative of BARC came to your home to visit?YesNoAre you willing to take the time to work with a dog on housebreaking or chewing, if such problems arise?YesNoPlease describe specific training methods you will use for housebreaking and chewing:Would you be willing to take the dog for obedience training if needed?YesNoAre you willing to take responsibility if this dog acquires an illness or test positive for heartworms?YesNoWill your dog be on heartworm prevention?YesNoIf yes, which type of heartworm prevention?Have all your current and previous dogs been on heartworm prevention?YesNoHow much time do you anticipate for your new pet to adjust to your home?How much time at the most will you allow the dog to adjust to your home?Are you financially ready and willing to provide the medical care your dog will need for its lifetime?YesNoIf something happened to you, who would care for the dog? Pet InformationDo you have animals now?YesNoIf yes, please list them below:Name, Breed, Male or Female, Age, Spayed/NeuteredIf any of your pets are not spayed/neutered, please explain why not:Are they current on vaccinations?YesNoNot ApplicableAre they on a heartworm preventative?YesNoIf yes, what happened to them?Have you had pets in the last five years?YesNoIf yes, please provide details for each pet below:Name of Pet, Breed, Age of dog, Years Owned, Spayed/Neutered, Inside/Outside, Please list approximate % of time inside and outside, Where is Pet Now? Current or Past Vet (Name of Clinic):Current or Past Vet (Phone Number):Are there any behavioral issues or special needs with any of your current pets?YesNoIf yes, please explain the behavioral issues or special needs:Have you ever had to surrender or re-home an animal?YesNoIf yes, please explain:Where was the pet surrendered to?Are you applying to adopt a pet from another rescue?YesNoIf yes, from which center?Have you ever adopted a rescue animal?YesNoIf yes, provide details:Group's name:Animal's name: Personal Reference (NOT RELATED)Name: First Last Relationship:Phone Number:Best time to contact:Comments:Please provide any other information you may want to include in regard to adopting this pet. PLEASE NOTE THAT IT MAY TAKE UP TO A WEEK TO PROCESS YOUR APPLICATION. If it appears you would be a good match for the dog you are applying or if we need any clarification, we will contact you after reviewing your application. The application must be complete with all questions answered in order to be processed. We reserve the right to disqualify any applicant if any of the above information is not accurate. Thank you for applying for a BARC rescue dog.Signature*By signing this, I acknowledge that I have filled out all of the above information truthfully on this date.