Ellens Rescue

Name

Address

City                                                                                     State                                                          Zip

Home Phone #

Work Phone #

E-mail Address

Occupation

Your Age

Please complete the following for each additional person living in your household on a regular basis:

Name

Age

Relationship

Occupation

Who will be caring for the dog?

Is everyone listed above in agreement on this adoption?     YES     NO (explain)

If you look after children, adults, daycare, run a business from home, please explain the circumstances:

About your Home

Apartment     Condo     Single-family house       Townhouse                   How long at address?

Do you own or rent?

If renting does the landlord allow pet?

Do you have a balcony?                          If yes, the space between the rails?

Would you be willing to make adjustments in your home for the safety of the rescued animal?

Is your yard fenced?                                  Approximate dimensions of yard: 

If YES, please specify the approximate height and type (chain link, privacy, invisible, other)

Landlord Information (if applicable)

Name

Company 

Address

Phone