Small Dog Rescue
ADOPTION APPLICATION
Purebred & Mixed Breed
(ALL DOGS ARE SPAYED OR NEUTERED)

All Questions MUST Be Answered, Unless Indicated as “Optional.”
Incomplete Applications Will Be Rejected!

Email your completed application to: application@tikiblackdog.com
________________________________________________________________________________

First & Last Name: ________________________________________________________________
Address: ________________________________________________________________________
City: _________________________State:_____________________Zipcode:__________________
Home Phone: __________Cell Phone (if applicable): __________Work Phone 
(optional):_________
Email Address: ___________________________________________________________________
Best Manner and Time to Contact You: ________________________________________________ 
Employment Status: Employed _____ Retired _____ Other (explain) _________________________
Ages and Number of Adults in Your Home – Fill in All Categories That Apply (below):
      21-25: _____					56-65: _____
      26-35: _____					66-75: _____
      36-45: _____					76-85: _____
      46-55: _____					86+:    _____
First & Last Names of Other Adults (21 and over) Living at Your Residence: ___________________ 
________________________________________________________________________________
Number of Children & Persons (under 21) in Your Home (including visitors) 
____________________
What Kind of Dog Are You Looking For: 
________________________________________________
What Activity Level in a Dog Are You Looking For - Very Active, Moderately Active or Low Level of 
Activity: _________________________________________________________________________ 
Have You Had Dogs Before: __________ If So, What Type(s)/Breed(s):_______________________ 
________________________________________________________________________________
What Happened to Your Dogs: _______________________________________________________
________________________________________________________________________________
Did You Previously Have Any Other Pets: _____ If So, What Happened to Them: _______________
________________________________________________________________________________
Will Your Dog Primarily Be an Indoor or Outdoor Dog: _____________________________________
Do You:  Own Your Home _____ Rent _____ Other (explain): 
_______________________________
Type of Residence(s) (Check Applicable Response(s) Below):
      House _____ Apartment _____ Condo/Townhouse _____ Mobile Home _____
      Other _____ (Explain) _____________________________________________
Years at Current Address: _____
Do You Have a Doggy Door: _____ If Not, Would You Install One: ___________________________
Do You Have a Fenced Yard: _____ If So, What Type of Fencing: ___________________________
Do You Have a Pool: _____ If So, Is It Also Fenced: _____ 
Have You Discussed This Adoption With All Members of Your Household: _____
How Do the Other Members of Your Household Feel About Adopting a Dog: ___________________
________________________________________________________________________________
How Many Hours Per Day Will Your Dog be Left Alone: 
____________________________________
When You Travel, or Go On Vacation, What Will You Do With Your Dog: ______________________
List Any Other Pets/Animals in Your Home/Household: 
____________________________________ 
________________________________________________________________________________
Do You Have a Regular Veterinarian: _____ 
      If Yes, Provide Name & Phone Number of Your Veterinarian: 
__________________________
Do You Have a Regular Groomer: _____
      If Yes, Provide Name & Phone Number of Your Groomer: 
_____________________________
A Dog Can Live for 15 Years or More – Are You Ready to Make That Kind of Commitment: ________
Any Other Additional Information You Wish to Include (optional): 
_____________________________
________________________________________________________________________________
CERTIFICATION
I certify that I am at least 21 years of age.  I understand that a dog can live for 15 or more years and I am 
ready to make that commitment and to provide proper food, water, shelter, health and other necessary 
care to any dog that I adopt from Small Dog Rescue for the adopted dog’s lifetime.  I further agree to 
notify Small Dog Rescue, should I become unable to fulfill any portion of my adoption commitment to 
them. I hereby verify that the information I have provided in this Adoption Application is true and 
accurate. I also understand that Small Dog Rescue reserves the right to refuse adoption for any reason.
Certify:   I agree: ______ I disagree: ______

MAKE SURE ALL QUESTIONS HAVE BEEN FULLY ANSWERED 
BEFORE SUBMITTING YOUR ADOPTION APPLICATION.

Please Email Your Completed Application to:
application@tikiblackdog.org