First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Work Phone
x

Cell Phone*

Alt Email

Which Special needs/placement dog are you applying for?*
Sorry, no animals found

Are you over 21 years of age?*

Do you (or anyone in your home) smoke tobacco? Pipe, cigar, cigarette? *

Why did you choose this dog?*

Should my application be approved, and I am selected to adopt, I understand and agree that Yorkie Rescue Houston will photograph me/my family with our adopted pet and by proceeding with this application, hereby give my consent to use our photo in any marketing endeavor. I also agree and understand there will be no compensation for any photo used.

If you are not local to the Houston metro area, please note, we DO NOT TRANSPORT. If you are approved for adoption, do you agree that you will come to Houston and personally transport your new pet home?*

Please list the ages of all children under 18 in the home. If none, say NONE. Please include any grandchildren who may visit regularly*

How many pets do you currently have?*
Choose one: I have no pets 1 2 3 4+

Identify ALL pets in the home Include:
NAME
SPECIES
AGE
WEIGHT

How much time will the animal spend alone during the day*

Where will the animal be kept when you are home*

Where will the animal be kept when you are not home*

Where will the animal sleep*

In what type of home do you live*
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

Is your yard fenced*
Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

What type of fence*
Choose one: N/A - No yard/no Fence Privacy Wrought Iron - MUST BE modified 24" up from ground Chain Link - Your application will not be approve Invisible - Your application will not be approved

What is the height of the fence. (or if NO FENCE, say NO FENCE)*

You have chosen to take in a special needs dog, possibly a hospice dog. By agreeing to adopt this dog, you agree to provide a comfortable, safe, and loving home environment until you and your vet determine s/he no longer enjoys life, has no quality of life and a humane euthanasia is appropriate. Please do not allow the pet to suffer. While it's hard to know for certain, s/he is counting on you to help them when the time comes. If this is a hospice dog, the adoption fee is waived for this pet. Please plan and prepare for the expense associated with end-of-life care and arrangements. If this is a special needs (medical) dog, the adoption fee is reduced.

I certify that the information entered on this application is true. Enter your name and date*