Harnessed to Hope Northern Breed Rescue Adoption Application

Harnessed to Hope Northern Breed Rescue
PO Box 21125
Lehigh Valley, Pennsylvania 18002

1-866-65-RESCUE • www.nbrescue.com
HTHNBR is a non-profit organization as recognized by the Internal Revenue Service
pursuant to Section 501(c)3 of the Internal Revenue Code.

Please answer all questions to the best of your ability. Missing information may cause a delay in processing your application.

Name:

*

Street Address: *

City *

State *

Zip Code: *

Home Phone: *

Cell Phone:

Best time to call: *

Morning

Afternoon

Evening

Email Address: *

Is age of applicant under 18?
If so, how old is the applicant? * 🛈

No

Yes Yes

Personal References:
Please list three references (only one can be a family member) *

	Name	Relationship	Phone Number
First Reference	Name	Relationship	Phone Number
Second Reference	Name	Relationship	Phone Number
Third Reference	Name	Relationship	Phone Number

How soon are you hoping to adopt a dog? *

Why did you select this time frame? *

Please list all members of the household: *

	Name	Age	Relationship
Self	Name	Age	Relationship
Other1	Name	Age	Relationship
Other2	Name	Age	Relationship
Other3	Name	Age	Relationship
Other4	Name	Age	Relationship
Other5	Name	Age	Relationship

Who will be the primary caretaker of the dog? *

Are there regular visitors to the home that the dog will be interacting with?
If yes, please describe (young children, elderly, other dogs, etc.) *

No

Yes Yes

Is everyone in the house agreeable to adoption? *

No

Yes

Do you own or rent your home?
If you rent do you have landlord permission? *

Own

Rent

Landlord Name: 🛈

Landlord Phone number:

NOTE: If you rent your home, please have your landlord fax a statement saying that your lease does allow you to have a dog. Please ask them to include any limitations on having a dog that your lease includes, such as maximum weight, any breeds that are prohibited, etc.

The statement should be faxed to 866-657-3728 (this is our fax number as well as our phone number) to the attention of Harnessed to Hope Volunteer Staff.

How long have you lived at this address? * 🛈

Do you have plans on moving?
If so, when? *

No

Yes Yes

If you move, what will you do with the dog?

Do you have a fenced in yard? *

No

Yes

What type of fence do you have? *

Describe Fence 🛈

What is the height of your fence? *

If you don't have a fence, do you plan on installing one? *

What kind?

If you do not have a fenced yard, how do you plan to toilet and exercise your dog?

Have you researched the breed(s) that you are interested in? *

No

Yes

What type of research have you done? *

Have you ever owned a: *

Do you currently have any dogs? If so, please list each one below. *

	Sex	Age	Breed
Dog 1	Sex	Age	Breed
Dog 2	Sex	Age	Breed
Dog 3	Sex	Age	Breed
Dog 4	Sex	Age	Breed
Dog 5	Sex	Age	Breed
Dog 6	Sex	Age	Breed
Dog 7	Sex	Age	Breed

Have you ever owned a dog in the past 10 years that you no longer own? If yes, please explain what happend to the dog you no longer own. *

No

Yes Yes

Do you have any cats?
If so, how many? *

No

Yes Yes

Are your cats indoor or outdoor cats? *

Have the cats ever met a dog?
If so, how did they get along? *

N/A

No

Yes Yes

Have you ever owned any cats in the past 10 years that you no longer have?
If so, what happend to the cats you no longer have? *

No

Yes Yes

Do you have any other pets?
If so, Please list here: * 🛈

No

Yes Yes

What breeds or mixes are you interested in? *

Why have you chosen this breed or mix? * 🛈

Is there a particular dog on our website that your interested in adopting?
If so, which one? (We do our best to match each adopter to the dog they like, but please note we cannot guarantee that this dog will still be available at the time of your adoption.) *

No

Yes Yes

Why are you interested in this dog? 🛈

Do you have a gender preference? *

No Preference

Male

Female

Reason for gender preference? *

Do you have an age preferance? *

Reason for age preference? *

Plans for dog: *

Characteristics
Please note the importance of each of these characteristics. We will use this information to find the right match for you. *

	Unnecessary	Willing to Train	Preferred	Essential
Housebroken	Unnecessary	Willing to Train	Preferred	Essential
Crate Trained	Unnecessary	Willing to Train	Preferred	Essential
Good With Babies	Unnecessary	Willing to Train	Preferred	Essential
Good With Young Children	Unnecessary	Willing to Train	Preferred	Essential
Good With Dogs	Unnecessary	Willing to Train	Preferred	Essential
Good With Cats	Unnecessary	Willing to Train	Preferred	Essential
Good With Small Dogs	Unnecessary	Willing to Train	Preferred	Essential
Good with Small Animals	Unnecessary	Willing to Train	Preferred	Essential
Turstworthy off Leash	Unnecessary	Willing to Train	Preferred	Essential
Trustworthy in house alone	Unnecessary	Willing to Train	Preferred	Essential
Has no known medical issues	Unnecessary	Willing to Train	Preferred	Essential
Good in Dog Parks	Unnecessary	Willing to Train	Preferred	Essential
Doesn't Pull on a Leash	Unnecessary	Willing to Train	Preferred	Essential
Does Not Dig	Unnecessary	Willing to Train	Preferred	Essential

*

	Crate	Loose in House	Loose Outdoors	Kennel Run	Tie Out	Basement	In Bed With Owner	Other
Where will the dog spend its time during the day?	Crate	Loose in House	Loose Outdoors	Kennel Run	Tie Out	Basement	In Bed With Owner	Other	Other
Where will the dog sleep at night?	Crate	Loose in House	Loose Outdoors	Kennel Run	Tie Out	Basement	In Bed With Owner	Other	Other

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

Do you currently have a veterinarian? *

No

Yes

Veterinarian Reference

Vet Name * 🛈

Vet Address 🛈

Vet City

Vet State

Vet Zip Code

Vet Phone *

As part of your adoption application, a volunteer with Harnessed to Hope Northern Breed Rescue will need to contact your current vet (if applicable) as part of the reference check. Some vets require that we have permission from you before they talk to us. Do you give your vet permission to talk with one of our volunteers? *

Is this your current Vet?
If not, Why? *

Yes

No-Please explain No-Please explain

Have you applied to any other rescue?
If Yes, which one(s)? *

No

Yes Yes

Do you agree to allow a represenative of HTHNBR to come to your home?
If no, why not? *

Yes

No-Please explain No-Please explain

How did you hear about us? *

Is there any additional information that you would like us to take into consideration? 🛈

🛈

Harnessed to Hope Northern Breed Rescue reserves the right to deny any application for any reason.

By clicking Submit below, you are attesting that all the information in this application is truthful. Any falsehood or misrepresentation is grounds for denying the application. You also agree that all members of the household are aware of and interested in adopting a dog, and will be at the adoption on the date agreed upon by you and by HTHNBR.

I agree to the above statement: *