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USA Pit Bull Rescue
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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
Raleigh, NC  27610


***USA Pit Bull Rescue Reserves The Right To Deny Any Application For Any Reason***

Personal Information:

Name:     ________________________________ Age:  _____________

Spouse:      ________________________________ Age:  _____________
Address:     ________________________________    


Phone:     _________________________ Home

          _________________________ Your Work and hours    

          _________________________ Spouse's Work and hours

Email:     _________________________________

Employer:      _________________________________________________________

Spouse's Employer:     _________________________________________________________

Number of Children:     ________
Names                                         Ages

     ____________________________               ______

     ____________________________               ______

     ____________________________               ______

     ____________________________               ______

Have any of these children been exposed to a Pit Bull Dog before?
_____Yes       _____No

Have any of these children been biten by a dog?  ___ Yes  ___ No

If yes, please explain the circumstance: 

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

 2.    Rent      Own       Live with parents

 3.     City    Suburban     Country

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?

Is 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:


If 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 pet?
  ____ YES    _____ NO

Besides your immediate family, are there others residing in your house?    
___ YES    ___ NO

Does anyone in your home have allergies or asthma:

If yes, names and relationship:



Does your home have a yard?        ___ YES    ___ NO

If yes, is it fenced?             ___ YES    ___ NO

What type of fence?      _______________________________________

How tall is the fence?     _______________________________________

Will 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

Placement Information:

Is someone home during the day?     ___ YES    ___ NO

If no, where will the dog stay while you are gone?


Where will your dog be kept most of the time?   
Inside   Outside   Basement    Garage  Other(specify):____________________

If kept outside, will you have a dog run and/or dog house?

Specify:  _________________________________________________________

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:  

Do 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    ___ NO

Have you ever owned a Pit Bull Dog?             ___ YES    ___ NO 

If yes, tell us about your Pit Bull Dogs:____________________________________

What sex do you prefer?     ___  male      ___  female

Age range_____________________________________________________
Is there a dog on our web page that you are interested in?  If yes, which one?


What steps have you taken to learn about Pit Bull Dogs and
dog ownership? ______________________________________



Will you accept a Pit Bull Dog with Special Needs?__ Yes __ No

Do you own a dog crate:  __ Yes  __ No

Do 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  ___ No

Why do you want a Pit Bull Dog?_______________________________________




Will the Pit Bull Dog be used as a guard dog? ___ YES    ___ NO


What activities do you plan to do with your Pit Bull Dog?



Other Pet Information:

Do you have any other pets?         ___ Yes    ___ No        

Are they current on vaccinations   ___ Yes    ___ No 

Name(s)                     Type (dog, cat, etc.)            Age    Vaccination Date

_________________  ___________________    _____  ___________

_________________  ___________________    _____  ___________

_________________  ___________________    _____  ___________

_________________  ___________________    _____  ___________

Are your animals on heartworm preventative?      ___ Yes    ___ No

What type?     ________________________________________

Are 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

Your veterinarian:

Name:  ____________________________________________________

Phone number:     ____________________________________________

If applicable, approximate date of your current pet's last office visit:



If you have owned other dogs and do not now, what happened to them?





Have you ever euthanized an animal for any reason to her than a termimal illness?
_______ Yes   _____ No
If yes, please explain:  ___________________________________________


Has an animal died in your home?  ____ Yes    ____ No
If yes, what was the cause? 


Who 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

Do 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: ______________________________________________________________

We 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?

___ YES    ___ NO


Please list three personal references:  (no family references)



Phone Number:       














Additional Comments: 
Do 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 pet?
____ Yes   ___ No
If yes, what is the name of the rescue group?  _______________________

Have 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.   

I, ___________________________ (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 ___ 200_. 

I understand total adopt is $250.

______________________________________________           __________          
Signature (signing this form acknowledges the above statements)          Date  

USA Pit Bull Rescue Inc" logos and slogans are Copyrighted 2007 by Diane Sacripanti and owned by Diane Sacripanti. All rights reserved

All text is Copyright 20071 by USA Pit Bull Rescue Inc. unless otherwise noted.

The information, pictures, slogans, designs and/or artwork, text included and forms on this website are protected under applicable state, federal and international copyright laws and is the sole property of USAPBR (unless otherwise noted) and may not be used in any way, shape or form without written permission from Diane Sacripanti. The material on this website may not be published, broadcast, rewritten or redistributed without permisssion from Diane Sacripanti.

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