Yorkie Friends Rescue Corporation
                                                             Application for Adoption

List the name of the dog in which you are interested:_________________________

Personal Information
Name___________________________________________ Age___________________
Spouse’s Name___________________________________ Age____________________
City____________________________ State_____________________ Zip___________
E-mail Address___________________________________________________________
Home Phone____________________________ Cell Phone  _______________________
Employer__________________________________ Phone________________________
Spouse’s Employer_____________________________ Phone_____________________
Number of children living at home_____________ Ages__________________________
Other than immediate family, list all living in your home and their ages______________
How long have you lived at this address? _________ Previous address, if less than 2 yrs.
________________________________________________ Years there_____________
What is the best way to contact you?  Phone   email    When?_____________________
Have you ever owned a Yorkie? ______ If so, 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? ______ Brand _________________________
Are all pets on flea control? _______   Brand __________________________________
Groomer’s name and phone (as reference)______________________________________
Veterinarian’s name and phone (as reference)___________________________________
Approximate date of last Veterinarian visit for each pet___________________________
List all pets you’ve owned in last 10 years, not mentioned above, and their present status.

General Information
How did you hear about the Yorkie Friends Rescue? ____________________
Please,list any Breed, Humane Societies, Training Clubs, and similar organizations you support or belong
Please, provide the name, address, and phone number of three 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 circle the term(s) that best describes you current living situation:
House    Condo     Apartment     Modular Home     
Rent     Own     Living with Parents
If renting, Landlord’s name _____________________________Phone______________
If living with parents, Parents’ Names: ____________________ Phone______________
If renting or living with other party, are pets allowed? ___________________________
Social environment (circle one): Urban     Suburban     Country
Does your home have a backyard? ______ Is it fenced? ______ Fence type___________
Fence height______ Will gate be padlocked? ______ Is fence permanent? ____________
Is edge of fence buried to prevent tunneling? ______  
Do you have a swimming pool or hot tub at your home? _________  Does it have a safety fence around it to prevent
dogs or children from falling in? __________
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? ______ Explain________________________
From what agency did you adopt? _____________________ Phone_________________
Do you prefer: male or female? __________ Age range? _______  Size? ____________
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: Circle all that apply:
Soiling floor    Dog/cat aggression    Excessive barking   Other _____________________
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 hw 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 willing 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)? ___________________________ (We do not
ship dogs.)

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 contact the references provided on this application. Please inform
your groomer and vet that we will be calling them for information about you. If they require you to sign a release in order
to give a reference for you, you must do so before we call them. If the vet or groomer refuses to give a reference for you
because you have not signed a release, it may result in denial of adoption. Home visits are made prior to adoption and
may be done on a random basis 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. In
the case of post adoption visits which reveal circumstances that have substantially changed or otherwise pose a threat
to the safety or well-being of the dog, YFRC may remove the animal from your premises after adoption without a refund
of moneys paid. I also understand that if I return the adopted dog, no refund of the adoption donation will be made.  I
understand the requirements for adoption of a rescue dog. I understand that adoption donations are not tax deductible.

Signature: _________________________  Date: _____________________

We require a hard copy of your signature prior to adoption certifying the above information. You may also print the form
out and mail it, with your signature to:
Yorkie Friends Rescue Corporation
c/o  Nancy Doherty
3060 North Atlantic Avenue #204
Cocoa Beach, FL 32931

Revised 11/02/10