Application

Adoption Appication

This application may be used to express your interest in adopting an Akita. All information must be entered completely and truthfully.

General Information

Name:
Phone:
Cell Phone:
Street Address:
City:
State:
Zip Code:
Date of Birth:
E-Mail Address:

Why do you want an Akita?

Do you currently have other animals? Yes No

If you have other animals, what kind:

	First Animal	Second Animal	Third Animal
Type
Breed
Age
Gender	Male Female	Male Female	Male Female
Spayed/Neutered	Yes No	Yes No	Yes No

Have you owned large dogs before? Yes No

If you have owned large dogs before, what breed were they and what happed to them?

People in your Household

Please describe other people living in your household:

	First Person	Second Person	Third Person	Fourth Person
Name
Age
Gender	Male Female	Male Female	Male Female	Male Female
Relationship to you

Please list names, ages, and relationships for any that could not fit in the above table?

Your Home

Do you own or rent? Own Rent
If you rent, does the lease permit large dogs (a copy will be required)? Yes No

How long have you lived at this address?
If you have lived here less than 2 years, what was your previous address?

Street Adress:
City:
State:
Zip Code:

What is the size of your lot?
Is the lot fenced? Yes No
If fenced, describe:
If not fenced, would you be willing to provide a fenced area or kennel run? Yes No

Where will the dog be kept during the day?
Where will the dog be kept during the night?
Where will the dog be kept when you are away overnight?

If there are not children and/or other animals living in your home, are there foreseeable times when the Akita would have to spend visiting time with children or other animals? Yes No
Explain:

Are there any unusual circumstances to which the Akita will have to adapt? Yes No
Explain:

About You

What is your occupation?
Employer Information:

Name:
Phone:
Street Adress:
City:
State:
Zip Code:

How long employed have you been employed there?
If less than one year, name and address of previous employer:

Name:
Phone:
Street Adress:
City:
State:
Zip Code:

What are your working hours?
If anyone else in your household is employed, identify and give name and address, and work hours:

Have you or anyone in your household ever been charged and/or convicted of any charge related to animals or child abuse? Yes No
If so, explain:

References

Please provide information on your veterinarian:

Name:
Phone:
Street Adress:
City:
State:
Zip Code:

Please provide information on 3 local individuals (not relatives) who knows or has known your other animals:

First Reference

Name:
Phone:
Street Adress:
City:
State:
Zip Code:

Second Reference

Name:
Phone:
Street Adress:
City:
State:
Zip Code:

Third Reference

Name:
Phone:
Street Adress:
City:
State:
Zip Code:

May we visit your home and check your references to verify the information you have provided? Yes No

Certification

By checking the following box, you signify that you understand that any misrepresentation of yourself or any untruths in the information which you have provided herein will invalidate any future adoption agreement and will give the Klemko Akita Rescue Family the right to reclaim the Akita without refund of any fees paid?

Please note that, prior to adopting, you may be required to provide your driver's license and social security numbers and to sign a printed copy of this application.

View our Pet List (courtesy of petfinder.org)

Shop at petsmart.com, or ShelterCare by clicking on the following ads and the Klemko Akita Rescue Family will receive a percentage of the purchase price.

Buy a gift certificate for the Klemko Akita Rescue Family from Dogs Wiggles & Grins