Mid-Atlantic Basset Hound Rescue

Adoption Application

If you are interested in applying to adopt from Mid-Atlantic Basset Hound Rescue, please complete this online form and click on the "Submit Application" button at the bottom.

Please list name and age of each adult in the household:
Applicant Name *	Applicant Age *

Second Applicant Name	Second Applicant Age

Third Applicant Name	Third Applicant Age

Fourth Applicant Name	Fourth Applicant Age

Street Address *

City *

State *

Zip *

Home Phone *

Work Phone

Cell Phone

E-mail Address: *

Type of Home *
Apartment/Condo Townhouse Single Family Home
Your Home is currently *
Rented Owned
If RENTING, does Landlord permit dogs?
Yes No Not Sure
Is there a size/weight limitation on allowable dogs?
Yes No Not Sure
If RENTING, Landlords name	Landlords phone

Do you have a fenced in yard? *
Yes No
If YES, please describe fence and yard

Number of Adults in household *

Number of Children in household *

Ages of Children

Does anyone in the household have allergies? *
Yes No
If YES, please describe allergies

Who will have primary responsibility to care for the dog? *

How many hours a day will the dog normally be left alone? *

Will this be your first pet? *
Yes No
What pet(s) have you previously owned?

What happened to them?

What dog(s) do you currently own?

What cat(s) do you currently own?

What other pet(s) do you currently own (please list)

If you currently own a dog, is it neutered/spayed?

What breed is the dog?

Who is your Veterinarian (Name and Phone Number)

What pet name and last name are your vet records under?

Why do you want to adopt a Basset Hound? *

What gender do you prefer? *
Male Female No Preference
What age do you prefer? *

Do you agree to have your Basset Hound spayed/neutered if not already done? *
Yes No
Where will your Basset Hound spend most of its time? *

Do you agree to return your Basset Hound to us if you are unable to keep it? *
Yes No
Are you willing to provide us with follow-up reports? *
Yes No
Have you applied to other rescues? *
Yes No
If YES, which rescue(s)?

How were you referred to Mid-Atlantic BH Rescue? *

When will you be ready to adopt? *


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