Adoption Application – Poodle Patch Rescue Inc 501 (c) 3 non profit Texarkana, TX

Please complete the form below if you are interested in adopting one of our animals. This application must be completed before we can allow you to meet the animal.

Name of Dog (or Dogs) that you are applying for adoption?
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Age
Your Relationship status
# of Adults in household
Number / Ages of children
Your Work Information
Employed ? Employer's Name? How long ? Position ?
Spouse Work Info
Spouse Employed ? Employer's Name? How long ? Position ? *
Do You Own or Rent?*
If renting, name & phone # of landlord
How long at this address?
Do you have a fenced in yard?*
Height Of Fence
What type of fence do you have?
How long will the dog be left alone each day?
Other Pets / Additional Information / Comments
Do you own a pet now?*
If so, please list them here with their name, age and breed....
Have you owned one in the past?
Please supply vets name and phone number as well as the last name that the pet was under at that time
Have you ever re-homed a pet and if so, what was the reason?
If you have never re-homed, if you had to, what reasons would those be for? (house training issues, aggressive behavior etc)
I acknowledge that Poodle Patch may request a home visit and or photos per their request.*
- Yes
What type of food would you feed your Poodle?
When you are not home, would you crate your dog, leave loose in the house, or leave outside un-attended?
List at least "2" references that we may contact and their contact numbers*
Contact Name Phone Number or email address
Additional Contact Information
Veterinarian's Contact Information
Please provide name & phone number.
Groomer's Contact Information - Please include ALL of this information - Name of Groomer, Phone number of Groomer, Name of Pet and Last Name that the pet was listed under.
Please provide name and phone number.
Email
Are you human?
Please enter the characters exactly as you see them in the above image. This field is case sensative.
Phone
This field is for validation purposes and should be left unchanged.

Contact Name	Phone Number or email address

Other Pets / Additional Information / Comments

Additional Contact Information