Your Last Name
Name & Age of Each Adult in Household
Address
City State Zip
Phone: (H) (W)
Email:
1. In what type of housing do you live? Apt./Condo Townhouse Single Family
2. Do you own Rent? If you rent, does your landlord permit dogs? yes no not sure.
Is there a size/weight limitation on allowable dogs? yes no
If renting: Landlord’s name
Landlord's Phone
3. Do you have a fenced-in yard? yes no
Description of fence and yard:
4. Number in household: adults Children. Ages of children:
5. Does anyone in the household have allergies? yes no
If Yes, describe:
6. Which family member will have major responsibility of caring for the dog?
7. How many hours a day would the dog normally be left alone?
8. How close is your nearest neighbor?
9. Will this be your first pet? yes no
What pets did you previously own?
What happened to them?
What pets do you currently own? cats dogs birds other.
If you currently own a dog, is it neutered/spayed? yes no
What breed Age Sex
10. Who is your veterinarian? Name
Vet Phone
What pet name & last name are your vet records under?
11. Why do you want to adopt a Basset Hound?
12. What sex do you prefer? male female Age preference
13. Do you agree to have your Basset Hound spayed/neutered
if not already done? yes no
14. Where will your Basset Hound spend most of its time?
15. Do you agree to return your Basset Hound to us
if you are unable to keep it? yes no
16. Are you willing to provide us with follow-up reports? yes no
17. How were you referred to Tri-State BH Rescue?
18. When will you be ready to adopt?
Signature: (All adult members of household must type in signature(s)

Date:
Additional Info and/or Comments:
A MINIMUM DONATION OF $200 IS REQUIRED, payable at time of adoption. The adoption fee is tax deductible to the fullest extent allowed by law. All dogs are spayed/neutered, inoculated and heartworm tested prior to adoption. If you do not hear from us, please call Sandy Gera or Bob Arnold at 610-388-2434, weeknights from 6:30 - 9:00 pm to follow up. DOGS WILL BE PLACED WITHIN THE NJ, NY AND EASTERN PA AREAS.