Adoption Application Reference Check Date Application Submitted to PRAR * Is This Reference Form Complete? * Yes - CompleteNo - Incomplete, waiting for more info APPLICANT INFORMATION Applicant Name * Applicant Name First First Last Last Partner Name (if any) Partner Name (if any) First First Last Last Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Applicant Age * Applicant's Phone Number * Applying for which animal(s)? * HOME / FAMILY INFORMATION Is anyone in the home on the DNA/DNF list? * YesNo Processor, skip this question, leave as NO unless instructed otherwise. Home Notes (Check Google Maps & Application) * 1. What is the listed fencing material & height on App? 2. View the home (arial view on Google Maps) and briefly describe (Small/Lg home, fenced, landscaping, junk everywhere, small/large yard etc... is it a nice, well kept home/yard?) 3. Does applicant have locks on gates, or are they willing to add them? History of Parvo in current home? * If "YES" Include any additional notes above Is Anyone in the home allergic to pets? * If "YES" Include any additional notes above REQUIRED ADDITIONAL INFORMATION / NOTES * 1. Who and what are the ages of the people that live in this home? 2. Applicant's Occupation - Do they work from home? 3. What other animals (breed, age, sex) live in the home? 4. How long would our pet be left alone per day, and where would they be kept? 5. Has Home ownership been verified with mortgage or property tax statement? OR has the landlord been contacted and have they approved A to adopt a dog? (Please list any restrictions) PERSONAL REFERENCES - Remind References That Answers Are Confidential! REFERENCE #1 Name * Phone * Relationship * Personal Reference # 1: * Answer all questions on the scripted text. Add any Additional Notes/Comments REFERENCE #2 Name * Phone * Relationship * Personal Reference # 2: * Answer all questions on the scripted text. Add any Additional Notes/Comments Name and Phone # of person designated to care for applicant's pets in the event of their death. * VETERINARY REFERENCE Name of Clinic Clinic Phone # * Employee Spoken With * Does This Clinic offer a complementary well check for newly adopted dogs? * YesNoNot Applicable / No Veterinary History Does Applicant follow vet instructions for care? * YesNoNot Applicable / No Veterinary History Does the clinic feel that this client would be a good forever home for a rescue dog? * YesNoNot Applicable / No Veterinary History Ask Vet Staff to tell you about any animals on this account for the past 5 years. List each animal's information below. Use the extra NOTES section if you need to. VET REFERENCE ANIMAL #1 - SEE INSTRUCTIONS BELOW 1. Name of animal 2. Species and Breed 3. Age 4. This Pet is Living/Deceased 5. Additional Notes/Comments - Are they current on bordetella and heartworm prevention? If they are past due for vaccines, is it by a few months? When were they due? Do they have a consistent vaccine history prior? Get details please. VET REFERENCE ANIMAL #1 CONTINUED is current on DAPPV (dogs) or FVRCP (cats) 1 is NOT current on DAPPV (dogs) or FVRCP (cats) IF NO - List when they last received the vaccines IS current on RabiesIS current on Rabies Is NOT current on RabiesIs NOT current on Rabies IS spay/neutered is NOT spay/neutered has a consistent vaccine history with this clinic does NOT have a consistent vaccine history with this clinic Check all that apply. Add any additional information / notes above in Vet Ref for Animal 1 VET REFERENCE ANIMAL #2 - SEE INSTRUCTIONS BELOW 1. Name of animal 2. Species and Breed 3. Age 4. This Pet is Living/Deceased 5. Additional Notes/Comments - Are they current on bordetella and heartworm prevention? If they are past due for vaccines, is it by a few months? When were they due? Do they have a consistent vaccine history prior? Get details please. VET REFERENCE ANIMAL #2 CONTINUED is current on DAPPV (dogs) or FVRCP (cats) 1 is NOT current on DAPPV (dogs) or FVRCP (cats) IF NO - List when they last received the vaccines IS current on RabiesIS current on Rabies Is NOT current on Rabies - IF NO - List when they last received the vaccinesIs NOT current on Rabies - IF NO - List when they last received the vaccines IS spay/neutered is NOT spay/neutered has a consistent vaccine history with this clinic does NOT have a consistent vaccine history with this clinic Check all that apply. Add any additional information / notes above in Vet Ref for Animal 1 VET REFERENCE ANIMAL #3 - SEE INSTRUCTIONS BELOW 1. Name of animal 2. Species and Breed 3. Age 4. This Pet is Living/Deceased 5. Additional Notes/Comments - Are they current on bordetella and heartworm prevention? If they are past due for vaccines, is it by a few months? When were they due? Do they have a consistent vaccine history prior? Get details please. VET REFERENCE ANIMAL #2 CONTINUED is current on DAPPV (dogs) or FVRCP (cats) 1 is NOT current on DAPPV (dogs) or FVRCP (cats) IF NO - List when they last received the vaccines IS current on RabiesIS current on Rabies Is NOT current on Rabies - IF NO - List when they last received the vaccinesIs NOT current on Rabies - IF NO - List when they last received the vaccines IS spay/neutered is NOT spay/neutered has a consistent vaccine history with this clinic does NOT have a consistent vaccine history with this clinic Check all that apply. Add any additional information / notes above in Vet Ref for Animal 1 Does the number of current animals on the application match with the number of animals on the veterinary account? * If no, please note above WHICH animals were not listed on the application. Any Additional Veterinary Notes? Applicant's plan to socialize and exercise this animal? * Applicants answer to Facebook Question * OPTIONAL ADDITIONAL NOTES Additional notes from Vets/Personal Refs. Any "red flags" that you see on this application Upload Any Additional Files/Photos Here Drop a file here or click to upload Choose File Maximum file size: 516MB PRAR Representative Processing Application * PRAR Representative Processing Application First First Last Last If you are human, leave this field blank. Submit Adoption Reference Check Form