ACC Adoption Application
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Have you ever owned a CBR?
yes
no
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Are you 18 years of age or older?
yes
no
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First Name
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Last Name
*
Street Address
Address Line 2
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City
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State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
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Zip Code
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Phone Number
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Valid Email address as we will respond directly to this
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Number of adults in household.
*
Number & Age of children in household
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Do you own or rent your home?
Own
Rent
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Please describe your property and it's setting.
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Type and dimensions of fencing
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To determine the hours the dog will be left alone daily, please describe work schedules of adults in household.
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Where will dog spend days?
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Where will dog spend nights?
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Please list any other pets including their species, age, and intact/altered status.
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How will dog be exercised?
Hunting
Agility
Walking
Retrieving
Swimming
Hiking
Other
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Are you willing to have a rescue volunteer visit with you and your family?
yes
no
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Are you willing to pay an adoption fee?
yes
no
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Do you agree to take your adopted dog to the vet regularly and tend to his/her veterinary needs in the future?
yes
no
Please provide us with a vet reference including contact information.
*
Please provide us with 2 other references, including their contact information.
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Have you ever been convicted of any animal cruelty charge?
no
yes
I do not have internet access and only had this form in printed format, therefore, I will promptly mail it to: ACC Rescue Committee Chair, 5560 Weatherby Way, Suffolk VA 23435.
i have no internet access so could not submit online.
*
Indicates Response Required
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