BlueMoon Meadows Online Adoption Application

BlueMoon Meadows - A Caring Place for Orphaned Pets

ONLINE ADOPTION APPLICATION

Submitting your application online will require you to make a $25 payment as a non-refundable application fee. Once you have filled out the form below, clicking on the SUBMIT button will then send you to Paypal, where you can authorize payment through your Paypal account (if you have one) or through a major credit card. Your application fee, if you are approved to adopt, will be applied to your adoption donation.

Be sure to answer all questions. You will be prompted to enter information if you fail to answer any required items.

DO NOT use the ENTER key to move between fields. Click, Tab or let the text wrap naturally.

Thank you!

Your Contact Information
Date: (mm/dd/yy )
Name(s) (both names if a joint application):
Street Address:
(Apt. #):		City
State :		Zip:
Home Phone plus Area Code (xxx-xxx-xxxx)
Occupation(s):
Work Phone plus Area Code (xxx-xxx-xxxx)		Cell Phone with Area Code
Email:
Driver's License Number:
Name(s) Pet(s)You are Interested In Adopting:
*Privacy Note: The requested information is for the private use of BlueMoon Meadows and will never be made public.*

Questionnaire
1) Have you ever owned a dog before?	YES NO (Additional dogs can be listed in question #5 below)	Do you still have that dog?	YES NO
*If yes*, list dogs name, breed, age & sex	Name: Breed: Age : Male Female	Spayed/Neutered? YES NO *If no*, please explain

2) What happened to your last dog?

3) Please answer the following questions, during the last five years:
a) Have you lost a pet (not through death)?	YES NO	b) Have you had one poisoned?	YES NO
c) Have you had an animal killed by a vehicle?	YES NO	d) Have you had an animal die due to disease?	YES NO If yes, what did the animal die of?
IF you answer YES to any of the questions in #3 - *Please explain.*

4) For what purpose do you want this dog?
5) Do you have any other animals?	YES NO	*If yes, please list below*
Name- Type of Pet		Age	Sex
			Male Female
			Male Female
			Male Female
			Male Female
			Male Female
Are all pets spayed/neutered?		YES NO
Due to the many health benefits accruing from spaying and neutering, as well as to prevent accidental litters, we require that all resident pets must be neutered/spayed.

6) Do you have children at home?	YES NO	*If yes, please list below*
Child Name		Age	Sex
			Boy Girl
			Boy Girl
			Boy Girl
			Boy Girl
			Boy Girl

7) Do you live in a house? (if NO, check dwelling)	YES NO Condo Apartment Duplex	8) Do you Rent? or Own?
9.) If you rent, do you have the landlord's written permission to keep a dog and proof of pet deposit where required?			YES NO
A copy of the landlord's permission will be required or we will not do the home visit or adoption without it, nor will we contact landlords to secure these documents.

10) Do you have a fenced in yard?	YES NO	What type of fencing? Height?
If you have a doggy door, does it open only into the fenced yard?		YES NO
If you live in an apartment/town home, is there a safe place to walk/exercise the dog?		YES NO
11) Is someone home during the day?		YES NO
If no, please explain
12) What provisions will be made for your dog if nobody is home during the day?		Loose inside? In crate? In fenced yard? Other

13) Do you intend to keep this dog primarily:	Inside Outdoors	Where will the dog sleep?
14) Do you have a sex preference?	Male Female No Preference	15) Do you have a color preference?	YES NO Color
16)What age range would you prefer?
Would you consider an older dog?	YES NO	If yes, to what age?
17) Are other members of your household aware that you are considering adopting a pet?	YES NO	Does everyone in your home want this dog?	YES NO

18) Are you prepared to assume the financial responsibilities of caring for an animal, including inoculations, heartworm preventative, veterinarian care, good quality food, licensing, etc.?			YES NO
Name, Address and phone number of your Veterinarian:
Vet /Clinic Name
Vet/Clinic Address
Phone Number
*Please let your clinic know we will be calling so they can release information to us.* In order for the application to be considered, the veterinary records for current resident pets must be complete and up to date; all resident dogs and cats must be vaccinated, and dogs must be on heartworm preventative. There are no exceptions to this requirement.
19) Do you understand that the dog you adopt must be kept on monthly heartworm and flea preventative?			YES NO

20) Are you planning to move in the near future?			YES NO
If yes, please explain. If yes, are you willing to give BlueMoon the new address? YES NO
21) Is anyone in your house allergic to animals?		YES NO
If yes, please explain how the allergy is treated if you are bringing in a dog.
22) Are you familiar with the animal control regulations in your area?		YES NO
23) What circumstances, in your mind, justify giving up a dog?
*24) Are you willing to allow a BlueMoon Meadows* representative to visit your home by appointment?**		YES NO

25) Please provide three references other than your veterinarian (Examples: groomers, dog trainers, rescue organizations, other pet owners.).
Name		Phone




26.) How did you hear about BlueMoon Meadows Inc.	Internet Search Petfinder Vet, Clinic, Pet Store, or Shelter Referral Breeder Dog/Obedience Club Transporting pets	Another Rescue Group Friend/Neighbor Hospital or Health Care Provider Other:

27.) Do you accept that to defray our program expenses for rehabilitating your dog and to help the next rescue there will be a donation payable immediately by check, cash, or money order upon adoption and delivery of the adopted dog?			YES NO
28.) Do you accept that the adopted dog may not be transferred to another party and that if the dog must be given up for any reason, he or she is returned to BlueMoon Meadows?			YES NO

Additional Comments
I have read and am in full agreement with the BlueMoon Meadows Inc. Terms of Adoption. By clicking on the submit icon below, I am attesting to the truthfulness of my answers. I agree the adopted dog shall not be kept exclusively outside, will be on regular heartworm and flea preventive for life, and will receive good nutrition, all vaccinations, and normal health care. I understand that falsification of any of the above information will be grounds to disallow the adoption. I further understand that BlueMoon Meadows, Inc. will always be interested in our adopted dogs and may at any time inquire about the welfare of the adopted dog during the life of my dog. I will also provide the coordinators with new e-mail addresses and changed home addresses and phone numbers as they occur, as well as annual updates on how my dog is doing in his/her new home.

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