WHO YOU ARE & HOW WE CAN CONTACT YOU
First Name		Last Name
Email Address		Home Phone	– –
Occupation
Work Phone*	– –	Fax Number*	– –
Cell Phone*	– –	Pager*	– –
Other Phone*	– –	Describe other phone type*
Best to call	Pick One Home Work Cell Other Any phone	Best time to call
Personal Reference		Reference Phone	– –
I am at least 18 years old	Pick One Yes No

YOUR HOME & HOME ENVIRONMENT
Address 1			City
Address 2*			Zip + 4	–
How long at this address?			Dwelling Type	Pick One Single family house Condo or Townhome Duplex/Triplex Mobile Home Other
If less than a year, please give previous address
If dwelling type is "other," please describe
Do you own or rent/lease?	Pick One Own Rent or lease	If rent or lease, do you have written permission to keep a dog?			Pick One Yes No
Is your back yard fenced?	Pick One Yes No	Fence height at lowest point		Pick One Less than 3 feet 3 to 4 feet 4 to 5 feet 5 to 6 feet Over 6 feet
Does drive- way enter yard?	Pick One Yes No	Gate latches functional and "dog proof?"		Pick One Yes No
Please describe your back yard
Is there a dog door?	Pick One Yes No		If yes, what size (inches)?	height width
If there's a kennel run, describe size, surface, & fence type & height				When will kennel run be used?

FAMILY & FRIENDS
Are you or any household member allergic to dogs or dog dander?	Pick One Yes No	Please describe these allergies and their severity
Do you have a spouse or domestic partner who resides in your home?	Pick One Yes No	Other live-in adults? Please describe
Are there children living in your home?	Pick One Yes No	If yes, what age is each?
Does everyone in the home want a dog?	Pick One Yes No	If no, please elaborate
Who will feed and care for your new dog?		Who will exercise the dog and how?
Describe frequent human visitors		Describe the pets that may accompany them

THE DOG YOU WANT
Breed	Pick One Labrador Retriever Golden Retriever Flat Coat Retriever Chesapeake Bay Retriever Don't care (note-- we normally have Labs only)				Sex	Pick One Male Female Don't care	Color	N/A Black Chocolate Yellow Don't care for Labrador only
Minimum age		years	Maximum age		years	Purebred, or is a mixed breed dog OK?		Pick One Purebred Mix OK
How many hours the dog will be left alone on most days
Describe why you prefer this combination of traits, particularly the desired age range
Describe what you expect of the new dog
Describe what you will do if the dog damages or destroys something of value to you
Describe how you will correct the dog's behavior, if the need arises
Where the dog will be when you're at home
Where the dog will be at night
Where the dog will be when you're out of the house.
Where the dog will be when you're on a trip

PETS YOU HAVE  OR HAVE HAD
Current dogs (breed, sex, age)
Current cats (number and ages)
Other current pets (describe)
If you've had dogs before, please describe them and what became of or them
If you have one, who is your veterinarian?	Name
	Street
	City
	Phone

COMMENTS & SUGGESTIONS

TERMS & CONDITIONS
Our primary concern is to achieve the best possible matching of dog with adopter and to assure the long term welfare of the dog, so we ask you to help us to do so by indicating your acceptance or non-acceptance of the following conditions by picking a "yes" or "no" answer for each, as applicable.
You agree to permit a pre-adoption home inspection.	Pick One Yes No
You agree to permit an FCRR volunteer to make occasional in-person post-adoption checks by appointment, following the adoption.	Pick One Yes No
You agree to notify us if you are unable to keep the dog for any reason, and to return it to us.	Pick One Yes No
You understand that FCRR may refuse any adoption application for any reason whatsoever.	Pick One Yes No
You will inform us of any changes in your address	Pick One Yes No
You understand that FCRR cannot know everything, including behavioral traits, about any given dog, and that you bear the final responsibiity in evaluating the dog's suitability for your family and your situation.	Pick One Yes No

Please review your answers for accuracy and completeness. Before clicking the "submit" button, print a paper copy of this application for your records. When you're ready to submit electronically, click the "submit" button. If for some reason your electronic submittal fails, fax your paper copy to 888-412-3382.

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