Dog Application Step 1 of 4 0% Please review the BARC dog adoption policies here.Date:* 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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? Yes No Are you presently: Employed Unemployed Retired Student Employer: General InformationType of residence: House Apartment Townhome Condo Mobile Home Farm Do you own or rent? Own Rent Are you planning on moving in the next 6 months? Yes No If yes, please note type of residence and location: If rental, are dogs allowed? Yes No Maybe Size Restrictions? Yes No If yes, Max. size: Complex Name: Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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? Yes No What type of fence & how high? Will you allow the dog to run loose? Yes No If yes, where? What is the approx. size of your yard? Do you have an invisible fence? Yes No Do you have a doggie door? Yes No How 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) Other If 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? Yes No Are you willing to take the time to work with a dog on housebreaking or chewing, if such problems arise? Yes No Please describe specific training methods you will use for housebreaking and chewing:Would you be willing to take the dog for obedience training if needed? Yes No Are you willing to take responsibility if this dog acquires an illness or test positive for heartworms? Yes No Will your dog be on heartworm prevention? Yes No If yes, which type of heartworm prevention? Have all your current and previous dogs been on heartworm prevention? Yes No How 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? Yes No If something happened to you, who would care for the dog? Pet InformationDo you have animals now? Yes No If 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? Yes No Not Applicable Are they on a heartworm preventative? Yes No If yes, what happened to them?Have you had pets in the last five years? Yes No If 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? Yes No If yes, please explain the behavioral issues or special needs:Have you ever had to surrender or re-home an animal? Yes No If yes, please explain:Where was the pet surrendered to? Are you applying to adopt a pet from another rescue? Yes No If yes, from which center? Have you ever adopted a rescue animal? Yes No If 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* Reset signature Signature locked. Reset to sign again By signing this, I acknowledge that I have filled out all of the above information truthfully on this date.