Name: _________________________________Date:

Address: ____________________________________________________________

___________________________________________________________

Phone Number: ________________________ E-Mail ______________________

Do you own or rent your home? _______________________________________

Attention renters

A copy of your lease or a statement from your landlord, that a large dog is permitted, must

be attached to your application or else it cannot be processed.

Are there other animals in the home? __________________________________________________________

What type of animals? _____________________________________________________________________

Children? Ages? _______________________

_______________________

Which veterinarian have you used or will you be using? (Please include a phone number if we can

use him/her as a reference): __________________________________________________________________________

Please give two references with phone numbers:

___________________________________________________________________

How did you hear about our organization?

____________________________________________________________________________________

Please take a moment to tell us more about you, your family and any previous pets that you may

have owned.

_____________________________________________________________________________________

______________________________________________________________________________________

Why do you want a golden retriever?

______________________________________________________________________________________

Are there any specific qualities that you are looking for in a golden retriever?

______________________________________________________________________________________

I certify that my answers to the questions and statements are true and correct.

________________________________________________ ________________________

Signature Date

Our program requires all of our dogs to be seen by a veterinarian to perform the following

medical procedures: spay/neutering, rabies vaccination, DHLPP, worming, heartworm testing and micro chipping

The $250.00 adoption fee does not constitute the sale of the dog.

Please return this form to : Autumn Valley Golden Retriever Rescue

P.O. Box 779