FieldsetInstructions Please fill in ALL questions to the best of your ability, regardless of whether or not the question is marked mandatory. For questions, please contact us at rottieempirerescue@gmail.com You MUST fill in the appropriate adoption application in order to adopt a pet from Rottie Empire Rescue.Adopter InformationPrimary Adopter's Name *The first and last name of the primary adopterSecondary Adopter's Name The first and last name of the secondary adopter (if any)Contact Email address *Please list the best email address for us to contact you at.Phone Number *Please provide a phone number for Rottie Empire Rescue to contact you with.Phone Call Times *Please list the best times for Rottie Empire Rescue to call your phone at. If you have a work phone number, please also list that with the times when we are able to call at that number.Age of Primary Adopter *Please list the age of the primary adopterAge of Secondary Adopter Please list the age of the second adopter (if any)Number of Children *Please list the number of children in your home. List "0" if none.Children's Ages Please list the ages of the children in your home, (if any listed above). Please also list if they have previous experience with pets.Residence InformationResidence Address *Please give the address where you and your pet will be living.Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryLength of Residence *How long have you lived at your current address?Rent/Own *Do you rent or own your current residence?RentOwnHome Type *What kind of home do you live in? Ex: Apartment, House, Townhouse, condominium, etc.Insurance Check *Have you checked with your homeowners insurance to make sure that you are able to own the breed of dog you are looking to adopt?Yes, and I can own this breed of dog.Yes, and I cannot own this breed of dog.No, I have not checked my insuranceI do not have homeowner's insuranceLandlord Name Please give your Landlord's name (if any)Landlord Phone Please give a phone number for your landlord (if you have one)Yard *Does your residence have a fenced-in yard?YesNoPet ExperienceAnimal Experience *Do you have experience with pets or animals? If so, please explain the context, the duration, and whether or not you owned the animal.Primary Owner *Have you been the primary owner of a pet before?YesNoOwner History *Beginning with a list of your currently owned pets, please list all of the pets you have owned in the last ten years and where they are now. Please include species, breed, and the age of the animal when you first owned it.Trainer? *Do your current pets have a trainer?YesNoNo current petsVet InformationVeterinarian *What is the name of your current Veterinarian?Vet Phone *Please give a phone number for your veterinarian.Vet Contact Permission *I understand that I must contact my veterinarian and notify them that Rottie Empire Rescue has my permission to call and ask for a reference checkYesNoDate of Last Vet visit What is the date of your last visit to the veterinarian?Spay/Neuter Are your current pets spayed and/or neutered?YesNoI don't knowVaccinations *Are all of your current pets up to date on vaccinations?YesNoUnsureNo current petsHeartworm *Are your current pets on heart worm prevention?YesNoUnsureNo current petsLifestyleDaytime *Where do you anticipate letting your pet stay during the day?Nighttime *Where will your pet stay during the night time?Vacation Care *Where will your pet stay if you travel?Why adopt *Why do you wish to adopt a pet?Family Agreement *Is your family in agreement about adopting a pet?YesNoUnsureGuard Dog Would you use your pet dog as a guard dog?YesNoUnsureActivities *What activities would you do with your pet?Surrender *Why would you give up a pet?Particular Pet *Is there a particular pet you are interested in adopting?ReferencesName of Reference 1 *Please list the name of Reference 1Ref 1 Phone *Please list a phone number for your first ReferenceRef 1 Email *Please give an email address for Reference 1Ref 1 Address *Please give a mailing address for your first referenceStreet AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryRef 1 Relationship *How do you know your first reference?Name of Reference 2 *Please give the name of your second reference.Ref 2 Phone Please provide a phone number for your second referenceRef 2 Email *Please give an email address for your second referenceRef 2 Address *Please provide a mailing address for your second reference.Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryRef 2 Relationship *How do you know your second reference?Acknowledgment *I understand that my electronically-generated signature is valid as a means of a legal signature for the purpose of this adoption application. I also understand that by typing my name in the field below, I also acknowledge that I have reviewed my answers given in this form and state that all of the information given is true and accurate.I acknowledge and agreeElectronic signature *Please type your name. VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: