USA PIT BULL RESCUE ADOPTION APPLICATION
The information you provide on this application will help us to find the most suitable dog for your family. Please
print it out and fill it COMPLETELY, and mail to:
USA PBR - Adoption
5613 Old Ridge Road
Bull Rescue Reserves The Right To Deny Any Application For Any Reason***
Name: ________________________________ Age: _____________
________________________________ Age: _____________
_________________________ Your Work
Work and hours
Spouse's Employer: _________________________________________________________
of Children: ________
Have any of these children been exposed to a Pit Bull Dog before?
Have any of these children been biten by a dog? ___ Yes ___ No
If yes, please explain the
If you do not have children, do you plan to have children some day?
If yes, explain
how this will affect the dog's placement in the household:
Please circle which of the following best describes
your current living situation:
1. House Condo
Apartment Mobile Home
Own Live with parents
3. City Suburban
If you rent:
Does your landlord allow pets? ____ Yes ____ No
Is there a
pet deposit? _____ Yes _____ No
If yes, how much money per pet or per household?
there a size or weight limit? ____ Yes ____No
If yes, what is the limit?
What is your
landlord's name and phone number?
How long have you
lived at this address? _________________
If less than 2 years, please list your previous address:
requested, renters must provide landlord statement/copy of lease indicating that a Pit Bull Dog may live on the premises,
address and phone number.
Name of Homeowner Insurance Company:__________________________
Insurance Agent Name
and telephone number: ________________________
Are they aware that you may have a Pit Bull Dog as a companion
____ YES _____ NO
Besides your immediate family, are there others residing in your
___ YES ___ NO
Does anyone in your home have allergies or asthma:
If yes, names and relationship:
your home have a yard? ___ YES ___ NO
If yes, is it fenced?
___ YES ___ NO
What type of fence?
How tall is the fence? _______________________________________
the gate be locked with a pad-lock? ___ YES ___ NO
If you do not have a fenced
yard, are you prepared to walk your dog on a
leash for potty breaks and exercise more than 3 times per day, regardless
of the weather conditions or time of day/night: ____ Yes ____ No
What is the maximum number
of dogs/pets allowed by city ordinance?
What are your local licensing fees/requirements:?
Is there a chance
you might move in the next 5 yrs? ___ Yes __No
If so are you willing to restrict your choice of housing to places where
a Pit Bull Dog is allowed? ___ Yes ___ No
Is someone home during the
day? ___ YES ___ NO
If no, where will the dog stay while you are gone?
will your dog be kept most of the time?
Inside Outside Basement
If kept outside, will you have a dog run and/or dog house?
Would you let the dog outside by itself occasionally if you
had a house with lots
of land and away from busy streets?
___ YES ___ NO
Check any of the following you feel are valid reasons for giving away a pet:
Fleas ___Too expensive ___Having a baby ___Sheds too much
___ Moving to another state
___Getting married or divorced
___ Chews or destroys household objects
___ Children will no longer
take care of it
___ Found a new place to live but they don't allow pets
___ Other reason: Explain:
you or your spouse travel frequently? ____ Yes ____ No
If yes, How often?
How long with the dog
be left home alone during the day?
Where will the dog sleep at night:
What will you do with your dog when you
need to travel or go on vacation?
Will you take your dog to obedience class? ___ YES
Have you ever owned a Pit Bull Dog? ___ YES
If yes, tell us about your Pit Bull Dogs:____________________________________
sex do you prefer? ___ male ___ female
there a dog on our web page that you are interested in? If yes, which one?
steps have you taken to learn about Pit Bull Dogs and
dog ownership? ______________________________________
you accept a Pit Bull Dog with Special Needs?__ Yes __ No
Do you own a dog crate: __ Yes __ No
you understand that the dog will take time to adjust to it's new surroundings
and that certain behavioral issues might
occur? __ Yes __ No
Are you willing to work with USAPBR to correct these issues?
___ Yes ___
Why do you want a Pit Bull Dog?_______________________________________
the Pit Bull Dog be used as a guard dog? ___ YES ___ NO
What activities do you plan
to do with your Pit Bull Dog?
Do you have any other pets? ___ Yes ___
Are they current on vaccinations ___ Yes
Type (dog, cat, etc.) Age Vaccination Date
___________________ _____ ___________
_________________ ___________________ _____ ___________
___________________ _____ ___________
Are your animals on heartworm preventative?
___ Yes ___ No
What type? ________________________________________
you willing to pay for a heartworm test? ___ Yes ___ No
What is the extent of your present
pet's obedience training?
Have you ever had a pet hit by a car or lost?__ Yes __ No
Phone number: ____________________________________________
applicable, approximate date of your current pet's last office visit:
you have owned other dogs and do not now, what happened to them?
you ever euthanized an animal for any reason to her than a termimal illness?
_______ Yes _____ No
please explain: ___________________________________________
an animal died in your home? ____ Yes ____ No
If yes, what was the cause?
are you adopting this companion pet for? _______________________
Are you able/willing to purchase a crate?
____ Yes ___ No
Do you plan to chain the dog in the yard at any time? ____ Yes ____ No
you plan to leave the dog in an outdoor kennel at any time? ___Yes __ No
How did you hear about the USA
Pit Bull Rescue Group?
List any Humane Societies,
Organizations, Breed or Training Clubs you are associated with: ______________________________________________________________
will attempt to provide you with an honest evaluation of temperament on any dog we have to place. Do you realize that
often times the complete history of a Pit Bull Dog may not be known and you may encounter some behavioral problems?
YES ___ NO
Are you willing to work with us on correcting these problems?
Please list three personal references: (no family references)
you give permission for a USAPBR Representative to visit your home prior to and after adoption to do follow up visits on your
adopted Pit Bull Dog?
___ Yes ___No
Are you currently working with another rescue group to adopt a companion
____ Yes ___ No
If yes, what is the name of the rescue group? _______________________
you applied with another rescue group in the past 24 months to adopt a companion pet? ___ Yes ___ No
(Please Initial) I certify that the information provided on this form is true and correct and understands that, prior to being
approved for adoption, this information will be verified. A home visit will be scheduled and all members of the household
must be present. If upon inspection we find that the information contained in this application to be false, we retain
the right to deny your application or remove the animal from your premises without a refund of monies paid. I am
also financially and physically able to care for this animal. I understand that proper food and veterinarian care can
be costly and I am able and willing to meet these requirements. Approved adoptions require a signed Adoption Contract
by the Adoptor and by the President of USAPBR to be valid. If upon inspection we find that the information contained
in this application to be false, we retain the right to deny your application.
_____ (Please initial)
I agree to notify USAPBR of any change of employment, family status, relocation and any other family changes.
(Please initial) I understand thqt USAPBR cannot guarantee puppies to be purebred Pit Bull Dogs and in some cases adults.
___________________________ (applicant's name) give _____________________ (Veterinary Clinic) permission to release
any and all requested documents on all pets that are or have resided in my household for the last five years from the date
of this application to a Representative of USAPBR. This authorization will expire 1 year from today, the ___day of ___
I understand total adopt is $250.
Signature (signing this form acknowledges the above statements) Date
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