Yorkie Friends Rescue Corporation
Application for Adoption
Personal Information
List the particular dog in which you are interested
Last Name First, First Name Last
Spouse's Name
E-mail Address
Home Phone
Cell Phone
Spouse's Employer
Number of children living in home
Other than immediate family, list all living in your home and their ages.
Previous address if less than 2 yrs.......................
How long have you lived at this address?
Years there
What is the best way to contact you?
Pet Information
Have you ever owned a Yorkie?
If Yes where is it now?
Do you have other pets?
List breed age and sex
Are all pets current of all vaccinations?
Are they spayed/neutered?
If no to either explain
Are all pets on heartworm preventative?
Are all pets on flea control?
Groomers name and phone number
Veterinarian's name and phone
Approximate date of last vet visit for each pet
List all pets you've owned in the past 10 years, not mentioned above, and their present status
General Information
How did you hear about Yorkie Friends Rescue?
Please list any Breed Clubs, Humane Societies, Training Clubs,or similar organizations to which you belong?
Please provide the name, address, and phone number for 3 professional or personal references.
Information Specific to Adoption
Is the adopted dog for your personal companion?
If not, for whom is the dog?
We do not adopt dogs as gifts for other parties.
Why do you want a Yorkie?
Is everyone in your home agreeable to adopting a rescue dog?
If not, who and why not?
Please check the term(s) that best describes your current living situation.
Modular Home
Living with Parents
If renting, Landlord's name
If living with parents, Parents' Names
If renting or living with other parties, are pets allowed?
Social Environment: Check One
Does your home have a backyard?
Is it fenced?
Fence type
Fence height
Will gate be pad locked?
Is fence permanent?
Is edge of fence buried to prevent tunneling?
Does your home have a swimming pool or a hot tub?
Yes or NO.
If yes, are they secured with proper fencing around that area?
Will dog be left alone during the day?
For how long?
Days per week
Where will the dog stay while you are gone?
Specifically what will be the dog's living situation? (Examples-run of house, confined to one area, garage or basement)
Will the dog be crated?
If so for how long?
How often?
Have you ever adopted any animal before?
From what agency did you adopt?
Do you prefer male or female?
Age range?
Do you understand that often times the complete history of a rescue dog may not be known?
Will you be willing to work with us to correct any possible behavior problems?
Social/Behavioral problems you could not handle: Check all that apply:
Soiling floor
Dog/cat aggression
Excessive barking
Will you take the dog to obedience training?
If so, where?
Will you always maintain necessary vaccinations for the dog?
Provide necessary veterinary care and treatment?
Have annual heartworm test?
Maintain regular heartworm & flea prevention?
Medical condition(s) you are not able to handle
Are you willing to keep the dog for life?
Under what circumstances would you give up a dog?
What activities do you plan to share with your dog?
Veterinarian you will employ, name, address, and phone
Are you wiling to pick up the dog at the foster home or to assist
with the transport if the dog is a long distance from your home?
What maximum distance could you travel (one way)?
List any other comments:
Please Read Carefully Before Signing and Submitting Application
I certify that the information provided on this form is true & correct. I am also financially and
physically able to care for this animal. I understand that proper food and veterinarian care may be
costly, and I am able to meet these requirements. Phone or personal interviews are conducted
after the receipt of the application, then vet, groomer, and other references are checked. I give
permission to YFRC to contact all references listed on my application. If the vet or groomer require
a written release signed by me to talk with you, I understand that I must sign said release prior to
the YRFC call to them. I understand that if YFRC calls and they refuse to give a reference for me, I
may be denied adoption. Home visits are made on a random basis prior to and following adoption.
If, upon inspection, we find that information contained in this application to be false or substantially
incomplete, YFRC retains the right to turn down your application for adoption or remove the animal
from your premises after adoption without a refund of the Adoption Donation. I understand that if I
return the dog to YFRC for any reason, the Adoption Donation will not be refunded. I understand
the requirements for adoption of a rescue dog from Yorkie Friends Rescue Corporation.
We require a hard copy of your signature prior to adoption certifying the above information.
Yorkie Friends Rescue Corporation
c/o Nancy Doherty
3060 North Atlantic Avenue #204
Cocoa Beach, FL 32931