ACC Adoption Application

* Have you ever owned a CBR?

yes

no

* Are you 18 years of age or older?

yes

no

* First Name

* Last Name

* Street Address

Address Line 2

* City

* State

* Zip Code

* Phone Number

* Valid Email address as we will respond directly to this

* Number of adults in household.

* Number & Age of children in household

* Do you own or rent your home?

Own

Rent

* Please describe your property and it's setting.

* Type and dimensions of fencing

* To determine the hours the dog will be left alone daily, please describe work schedules of adults in household.

* Where will dog spend days?

* Where will dog spend nights?

* Please list any other pets including their species, age, and intact/altered status.

* How will dog be exercised?

* Are you willing to have a rescue volunteer visit with you and your family?

yes

no

* Are you willing to pay an adoption fee?

yes

no

* 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.

* 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