ADOPTION EVALUATION FORM

PART 1- Contact and Personal Information

Date:
Age/DOB:
Full Name:
Address:
City/State/Zip:
Phone#:
Email:
Occupation:

Do you live with:   Spouse/partner    Roommate's)    Parents    Alone

How many adults (21 and older) in your household?

How many individuals under 21 in your household?

What are the ages of the individuals under 21?

Can you drive to TLR to pick up a dog?

If needed, would you pay for or assist with shipping expenses? YES    NO

PART 2- Liability and Responsibility

By checking YES you agree to absolve TLR and all of its representatives from any liability in reference  to a dog featured in this web site. YES    NO

By checking YES you agree that the dog will not be used in any illegal activities nor be found at any  time in a municipality where Pit Bull presence is illegal. YES    NO

By checking YES you agree that the dog is to be kept as a house pet. It shall not be sold for medical or  experimental purpose, and it shall not be used for breeding. YES    NO

PART 3- Dog's) You Are Interested In Adopting

Choice#1 (required)

Choice#2 (optional)

Choice#3 (optional)

Choice#4 (optional)

Are you looking for a:  Male    Female    Either

Do you prefer a:  Puppy    Adult    Either

If you have a preference in color and weight, please describe it here:

Prefer dog to be: (check all that apply)
Already spayed or neutered
Not spayed or neutered
Doesn't matter

Additional requirements about the dog you would like to add:

PART 4- Living Situation and Lifestyle

Dog's living situation (check all that apply)
Dog will be house pet, living inside with family
Dog will live in basement or garage
Dog will live outdoors
Doghouse provided
Guard Dog for: Business    Residence
Other - please specify:

How many hours a day will dog be home alone?

When home alone dog will be (check all that apply):
In a crate, wire cage, or dog pen inside  
In a Kennel:   Outdoor    Indoor    Both
Tied up outside:   Cable Run    With a chain
Dog will be loose:   Indoor    Outdoor
Other - please specify:

How will you exercise the dog? (check all that apply)
Leash walks every day
Will have cable or dog run in the yard
Will be free to run in fenced yard
Will have supervised access to unfenced yard
Will be free to roam around (Off leash and unsupervised in unfenced area)
Will bring to dog park (Public area where dogs can run and play together off-leash)
Other:

Is the home in an Urban Suburban Rural setting?

Yard size is: Small    Medium    Large    Acreage    No Yard

Is the yard enclosed by a fence? YES    NO

If so, height, length, and type of fence:

Do you live in a House    Apartment ?

Do you own the property? YES    NO

If you are renting, please provide Landlord's name and phone number for verification
Land Lord's Name:
Phone#

Does your municipality have breed specific restrictions?
YES   NO    Don't know

If so, please describe the nature of the restrictions:

PART 5- Other Pets and Experience

Do you have other DOGS? (Check all that applies)
No other dogs
One or more spayed female
One or more neutered male
One or more un-spayed female
One or more un-neutered male

Please specify breeds and ages of other dogs: 
Breed: Age: Spayed Neutered
Breed: Age: Spayed Neutered
Breed: Age: Spayed Neutered
Breed: Age: Spayed Neutered

If you had other dogs in the past, please let us know their current disposition:
Still have the dog's)
Died of old age fatal disease
Gave or sold to friends, relatives or acquaintance
Was hit by a car
Was stolen
Disappeared/Lost

Please specify what happened:

What other kind of animals do you own?

Of all the breeds available why do you want a Pit Bull ?

Experience: Please relate any prior experience you have had with this breed:

References: Please supply the name and phone number of your current veterinarian, or the one who saw your previous pet's), with their title identification. If you don't have a vet, please provide the name of your employer, clergyman, or anyone not related to you who can attest to your character. Vet references are preferred.
Character Reference
Name:
Relationship to you:
Phone#

Veterinary Reference
Veterinary Clinic:
Name of veterinarian:
Phone#

Additional information you would like to provide about yourself and/or the dog you would like to adopt:

Signature: Date: