Name
*
First Name
Last Name
Date of Birth
*
Please note you must be 21 years of age to adopt from Nirvana Animal Rescue
MM
DD
YYYY
Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employer
*
Are there other adults in your home?
*
Yes
No
If yes, please list the full name and date of birth for all the adults living in your home.
Are there children in your home?
*
Yes
No
If yes, please include the ages of all children in the home.
Personal Reference #1
*
Please list a reference who is NOT related to you or to anyone living in your home.
First Name
Last Name
Personal Reference #1 Email
*
Personal Reference #2
*
Please list a reference who is NOT related to you or to anyone living in your home.
First Name
Last Name
Personal Reference #2 Email
*
Do you rent or own your home?
*
Rent
Own
If you rent, please include your landlord name.
If you rent, please include your landlord's phone number.
(###)
###
####
If yes, what kind of fence do you have?
Chain link
Post and rail
Vinyl
Privacy
Electric
Other
Do you have a pool?
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Yes, in-ground
Yes, above-ground
No
If yes, do you have a fence around your pool and/or a secure cover?
Yes, fence around the pool
Yes, loop-loc cover
Yes, cover
No
Do you currently own any pets?
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Yes
No
If yes, please include the name, species, breed, gender, age, and weight of all current animals.
If yes, please include your veterinarian's phone number.
(###)
###
####
Have you owned any pets previously?
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Yes
No
If yes, please include the name, species, breed, gender, age, and weight of any previous animals. Please include what happened to each animal (death, rehomed, lost, taken to shelter, etc).
Why are you interested in adopting?
*
The age of dog I am interested in is
*
Please select all that apply
The size of dog I'm interested in is
*
Please select all that apply
The gender of dog I am interested in is
*
I am away from the home, on average, each day for:
*
2 hours or less
4 hours or less
4-8 hours
8+ hours
When I'm away from the home, my dog will stay
*
Inside, in a crate
Inside, in a playpen/gated off area
Inside, confined to a room/floor of the home
Inside, free reign of the home
Inside the garage
Outside
My dog needs to be good with
*
Please select all that apply
I'm comfortable with a dog with medical or behavioral needs
*
Yes, medical needs
Yes, behavioral needs
No
No preference/I'm open
I'm comfortable working with a dog trainer/behaviorist to address unwanted behaviors with my adopted dog
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Yes
No
What behaviors are you not willing to work with a trainer/behaviorist on?
*
Please feel free to add anything else that may help us match you with a dog here!
How did you hear about Nirvana Animal Rescue?
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Facebook
Instagram
TikTok
Adopt-a-Pet
Nirvana Animal Rescue Website
Friend/Family Member
Adoption Event
Foster Family
Word of Mouth
Other
Terms of Agreement
*
