ADOPTION APPLICATION Complete an adoption application today to arrange a Meet-And-Greet and Home Visit with your rescue dog. For more about the adoption process click here. A representative from Cody’s Friends Rescue will contact you within 2-4 business days. If you have any questions please email us at email@example.com. 1 Applicant Information2 Your Home and Family3 Current and Past Pets4 Your New Dog5 Veterinary References6 Finished Subscribe to our newsletter. Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Last Email* Subscribe to our Newsletter! Get updates on available dogs, fundraisers and news on Cody's Friends Rescue! Phone*Are you at least 25 years of age or older?*YesNoDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Address Line 1 Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please provide name or description of dog you are interested in.*Please provide name or description of 2nd dog of interest, if 1st dog is no longer available.Does everyone in the family want a dog?*Have you ever had financial responsibility for a pet?* Yes No Save and Continue Later Please check applicable box below regarding your home.* Own single family home Rent / lease single-family home Own / rent / lease townhome Rent / lease an apartment If renting, please provide name of complex or landlord and phone number.* Do you have any breed or weight restrictions regarding pets?* Yes No If Yes to restrictions above, please describe below. Otherwise, please enter N/A*We call to confirm any and all pet policies and restrictions on rentals.If you have children living in your home, please list the age of each individual child below.*Is your yard or a portion of your yard securely fenced?*YesNoPlease describe type (wood, chain-link, etc.) and height of fence. Include information on gates (type and how they are secured).*Would a dog be able to dig under your fence?*YesNoIf you have a pool, how is it secured?*If you do not have access to a fenced area, how and where will your new dog relieve itself and get adequate exercise?* Save and Continue Later Current and Past PetsHave you ever sold, given away, or surrendered a pet?* Yes No If you answered Yes to above, please describe the circumstances*Please list name, breed, and sex of all pets currently living in your home.*Are all of your current pets altered (Spayed or Neutered ie "Fixed")* Yes No If no, please describe how many unaltered and why:*Do you have a pet now or have you during the last 5 years? Yes No Please list all pets you have owned in the last 5 years that are no longer with you. Include type of pet (dog, cat, etc.), and why they are no longer with you.* Save and Continue Later Your New Dog's LifestyleApproximately how many hours a day will your dog be left alone?*Where will your dog spend the day?* Loose Indoors Crate Garage Kennel Run Loose Outdoors Please describe percentage of time or when your dog will be outdoors*Where will your dog sleep at night?*Your new dog may not be housebroken. Are there rugs, furniture, etc. that you cannot tolerate being soiled or chewed? How will you work with this issue?*To facilitate the bonding process, would you be willing to participate in obedience training with your dog? If not, please explain why.*Your new dog will need at least 4-6 weeks to acclimate and become familiar with your home and family. How will you handle housebreaking and the acclimation period during this time?*What will you do if you need to move and the new apartment or home will not allow your dog?*Under what circumstances do you feel you would re-home your dog, and how would you go about it?*When you travel, who will care for your dog while you are away?*New dogs in the home require a big commitment of time, energy, money, and love. Are you and your family confident you are ready for this kind of commitment?* Save and Continue Later Veterinary ReferencesPlease give information below on a veterinarian you have used for your current or past pet during the last 5 years. NOTE: PLEASE MAKE SURE YOUR VET IS AWARE THAT WE WILL CALL AND IS GIVEN PERMISSION TO RELEASE RECORDS. Name* First Last Phone*Address* Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Has this vet provided vaccinations for your past or current pets for the last 5 years?*YesNoIf No to above, please list name and number of clinic or vet who has administered vaccines for your pets. If clinic does not keep records, vaccination receipt will be acceptable for processing your application.*Have your pets been on heartworm prevention for the last 5 years?*YesNoPlease list where your heartworm prevention has been purchased (or by what vet). If your pet has not been on heartworm prevention, please explain why below.* Save and Continue Later Please Sign and Date BelowDo you understand that it may cost approximately $1200 a year for veterinary care, grooming, and proper food, and that the lifespan of a dog may reach 15 years or more?*By signing this application, I acknowledge that all my statements are true and correct. I state that I have never been accused or convicted of animal cruelty or neglect. I also state it is my intention to give the dog I adopt love and respect, welcome this dog as a part of my family and into my home, and be dedicated to working through any problems that may arise with this dog.*SignatureDate Date Format: MM slash DD slash YYYY Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.