Miranda's Rescue is often an animal's last and only chance. By adopting a pet from Miranda's Rescue, you too become a rescuer! The history of many of our animals is largely unknown, and the worst should be assumed. We recommend a prompt check-up by your veterinarian. Please initial here (    )

Name:			_______________________________________

Address:		_______________________________________

			_______________________________________

			_______________________________________

Phone(home):		_______________________________________

     (work/other):	_______________________________________

Place of Employment:    _______________________________________

Position:		_______________________________________

Type of Residence:	_____House   _____Apartment   _____Condo

			_____Own     _____Rent
			
If renting, please supply landlord's name and phone:

			________________________________________

Have you ever owned a dog before?   		_____Yes    _____No

     If yes, do you still have it?  		_____Yes    _____No

     If no, what became of it? _________________________________

If you presently own other dogs:

     Are their shots current?        		_____Yes   _____No

     Are they spayed/neutered?       		_____Yes   _____No

     Are they licensed?              		_____Yes   _____No

Who is/will be your veterinarian? _______________________________

Will the dog be indoors or outdoors?___Indoors ___Outdoors ___Both

Do you agree to keep your dog's shots current?	_____Yes   _____No

Do you agree to keep your dog/puppy in a 
securely enclosed area?         		_____Yes   _____No

Are you aware that a dog often requires a lot 
of attention and training to become a good 
neighbor and not a neighborhood nuisance?	_____Yes   _____No

If for any reason you cannot keep this 
dog/puppy, do you agree to return it to 
Miranda's Rescue?                 		_____Yes   _____No

Are you aware that providing an animal 
adequate food, water, shelter, and
freedom from abuse is required by law?		_____Yes   _____No

Do you agree to allow Miranda's Rescue to 
check on the dog's welfare from time to time?   _____Yes   _____No

Do you understand that, if any of the above requirements are not met, or if 
unverifiable or false information is provided in this application, Miranda's 
Rescue retains the right to have the animal returned to the organization?

						_____Yes   _____No

Do you understand that this application 
constitutes a contract between you and 
Miranda's Rescue?				_____Yes   _____No

How did you hear about Miranda's Rescue?  __________________________

Signature: ___________________________________________ Date:______________
_________________________________________________________________________________________________
Office Use Only
Dog's Name:_______________________________________ ID#:___________________

Adoption Date:___________________________

Approved: _______Yes _________No

Remarks:_________________________________________________________________________________

	_________________________________________________________________________________

Interviewer: ___________________________________________________

Amount Paid: $_________($_________adoption fee + $__________donation)
		Circle one: cash / check