SusieQ Dog ResQ
P.O Box 236, Conesus, New York 14435
(585) 346-6747
ADOPTION APPLICATION (fill in boxes)
Adopter’s Name: Animal you are interested in
Current Address: (how long?)
City: State: Zip: occupation
Phone # (Home) (Cell) (Work) Email address:
Do you Own Rent If renting, Landlord Information: Name Phone#
Do you live in the: City Country Suburbs
Veterinarian or Vet Hospital name Phone #
(please contact them and give them permission to speak to us)
How many adults in the household? Children - Boys? Age? , Girls? Age?
Who will be the main person responsible for the dog? Feeding? Walking?
Obedience training helps to create a special bond between dog and owner and makes a better canine citizen. Knowing this are you willing to take extra steps and enroll your dog in obedience classes?
Please tell me a little bit about yourself and why you’re interested in adopting this pet:
Where will pets living quarters be? Daytime Nighttime
How many hours will pet be left alone What brand of food do you normally feed?
How will the dog be restrained when it is outside?
Leashed walks Securely Fenced Yard Runner Line Chain
Invisible Fence Other (explain)
List your pets from now and the past
X if still owned / Cat or Dog? / Name / Breed / Age / M/F / Licensed? (if dog) / Spay or Neutered / If No Longer Owned – Why?Please give us the names and numbers of two references and please let them know we may be calling.
#1. Name Relationship Phone
#2. Name Relationship Phone
When considering adoption I understand others have already invested, both emotionally and financially, in the animal’s welfare. I acknowledge this involvement and therefore agree to continue their commitment by:
1. Working in partnership with my veterinarian to provide proper care, including vaccinations, heartworm medication and treatments, and spaying or neutering if this hasn’t already been done.
2. Providing a safe, healthy and happy environment.
3. Agreeing that decisions about where I choose to live will always include my new family member.
Thank you for filling out this form that allows us to find the best possible home for the rescued dog
we have grown to love.
By signing I affirm that I am 21 years of age or over, and that the
information contained on this form is true to the best of my knowledge.
I understand that if approved for adoption, I am prepared to make
a lifelong commitment of time and money to my pet.