300 W Bailey Street, Asheboro, NC 27203


Applications with missing information will not be accepted or processed

Pet(s) you are interested in
Name of person(s):
Place of Employment
How long

Pet Information

Do you currently have other pets at home?
please list Names, Breed, Age & Sex, Spayed or Neutered, Current on Vaccines & HW prev for dogs?
Species Dog-Cat-Other Check all that apply

What Veterinary Hospital(s) and what names would the records be under for the pets listed?

Vet office or Vet Hospital(s) used
name pets would be listed under
How many pets have you had in the past ten years?
List Name, Breed, Passed Away?, When? Why? Given, Away, Given to, Shelter, Lost Stolen Sold:
Please check correct option for your living situation:*
Land Lords phone number
Please check the correct option for your living situation:*
What type of Pet are you interested in adopting?
Gift for whom?
Do you have any of the following means of dog restraint? Check all that apply:*
Height of fence?
Where will your adopted dog spend most of the day?
If indoors where?
Where will your adopted dog reside when you are not at home?
If indoors where when you are not at home?
Where will your adoptd dog sleep at night?
If indoors sleeping at night where?
If you have a certain dog in mind why do you feel this dog is right for you?
How many hours will your dog be left alone each day?
How many adults reside in your home?
How many children reside in your home?
what are their ages?
How often and how many children frequint your home?
What is the relationship of the chilren who visit to the applicant?
Are you seriously willing to teach all children how to properly interact with the adopted dog?
Are all members of the household in favor of adopting a pet?
Has anyone in your home experienced allergies to animals
Is anyone in your household afraid of dogs?
Will other dogs or cats visit the home often?
If so, what breeds are they and are they social?
Who will be responsible for veterinary costs?
Are you aware that certain breeds require professional grooming every 6-8 weeks?
If your adopted dog had a medical emergency costing hundreds of dollars or more to treat, how would you cover the cost?
Who will be responsible for feeding the dog, taking care of its bathroom needs and cleaning up after it?
What is your plan for relieving your dog (bathroom)?
Have you ever taken an obedience class?
Have you ever house trained a dog?
Are you willing to housetrain a dog or puppy?
Are you aware that changing a dog's environment may causie it to have accidents?
Are you willing to obtain a crate for inside your home to train your newly adopted dog?
fue you willing to give your dog time to adust to its new environment and family?
Would you be willing to attend an obedience class with your adopted dog?
If a behavioral issue arose would you be willing to take the time to work through it?
How do you plan on exercising your dog?
Why do you want to adopt a dog?
What pet behavior is unacceptable to you?
Have you ever given away, sold, or surrendered a pet? If yes please explain below:
Reason for surrendering, selling, giving away, or selling:
Have you ever been issued a warning or citation for an animal control ordinance violation or had an animal legally removed from your care?
If yes, explain:

Please list two references other than family members below:

Reference one Name:
Refernce one Phone:
Reference one E-mail:
Reference one Relationship:
Reference two Name:
Refernce two Phone:
Reference two E-mail:
Reference two Relationship:

If for any reason you cannot keep your adoption commitment, you must contact us so the we can arrange the surrender back to the RSPCA.

By signing below, I certify that the information I have given is true and that I recognize that any misrepresentation of the facts may result in my losing the privilege of adopting a pet from the RSPCA. I authorize investigation of all statements on this application.

Signature: please type full name