Harmony Rescue Adoption Application

Please fill this form out completely. If a field does not apply, please insert "N/A" for Not Applicable.
Your form will not be submitted if any fields are left blank! Use the TAB key to move to the next question.


First Name A value is required.		Last Name A value is required.
Address A value is required.		City A value is required.		State A value is required.	Zip Code A value is required.Invalid format.
Home Phone A value is required.		Work Phone A value is required.		Cell Phone A value is required.	Fax A value is required.
e-mail A value is required.Invalid format.		Alternate e-mail A value is required.
Best time to call you? Morning Afternoon Evening Please make a selection.

Please indicate which animal you are interested in adopting: A value is required.			Comments: A value is required.

Are you 18 years of age or older? Yes No Please make a selection.			Comments: A value is required.

Are you employed? Yes No Please make a selection.		Occupation: A value is required.		Name of Employer: A value is required.	Working Hours: A value is required.

Do you rent or own? Rent Own Please make a selection.	If you rent, please list rental agent's name and telephone number (including area code): A value is required.

List all the people residing in your current household (first names, ages, relationship to you). Also, list all the pets currently residing in your household (name, species, breed, age): A value is required.

How would you describe your family's lifestyle and how a new animal would fit in -- Be specific! The more you can tell us about your family, the more we will be able to tell if this is a good match for you. You cannot tell us too much--every detail will help. A value is required.

Describe your home and yard (location, set up, fencing including height, provisions for the animal, where the animal will sleep, where the animal will be kept when no one is at home, where the animal hangs out, where the animal will receive exercise): A value is required.

Tell us about other animals have you had. What happened to them? A value is required.

What behaviors would you consider unacceptable: A value is required.

For Dogs: Describe the way you will train your dog to be a good "family dog." Please be detailed: Comments or N/A if you are not interested in a dog. A value is required.

What would happen if this animal developed physical or behavioral problems that you felt you could not handle or simply, your pet is now old: A value is required.

Are all of your current pets spayed/neutered? Yes No Please make a selection.			If no, please explain: Enter comments or N/A A value is required.

Do all your current pets receive an annual wellness exam from your vet? Yes No Please make a selection.			Comments: A value is required.

Do you provide a flea/tick application monthly? Yes No Please make a selection.			Comments: A value is required.

Please provide the name and telephone number (including area code) of your current (and former) vets for the pets you currently in your household. What pet names would the vet office have on record?: A value is required.

Please provide at least one personal reference who is not a family member or living with you (list name, e-mail address, home phone, work phone, and/or cell phone. Remember to include area code. The easier it is for us to contact your personal reference, the quicker we can process your application! Provide as many different ways to contact your reference as possible): A value is required.

Have you ever given up a pet? Yes No Please make a selection.			If yes, please explain: A value is required.

Have you ever been convicted of animal cruelty? Yes No Please make a selection.			Comments: A value is required.

What questions/concerns do you have about adopting one of our animals? Enter comments or N/A A value is required.

I certify that the information entered on this application is true. Enter your name and date: A value is required.

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Once you click submit, your application will be sent to Harmony Ranch and Rescue and you will be returned to the Harmony home page!

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Harmony Rescue Adoption Application