Today's Date:
Your name:			Home phone:
Email address:			Work phone:
Street address:
City, State, Zip:

What type of Affen are you most interested in adopting (age, sex)?

Would you be willing to adopt an Affenpinscher mix? Yes No

Would you be willing to travel by car or airplane to pick up a rescue? Yes No

What situations would cause you to not be able to keep this dog?
Do you understand that in the event you are no longer able to keep this dog, you are required to return it to Affenpinscher Rescue? Yes No
As with any rescue dog, Affenpinschers are often not housebroken, have been abused in the past, or may have treatable medical problems and in some cases, these types of problems may not be realized until after the dog has been placed in its new home. If you are approved for adoption, are you willing to work with your new pet to give it the new life it deserves? Yes No
Please provide a brief paragraph describing yourself and how you would like to be contacted.
Which of the following bests describes your current residence?
Own Home Rent Apartment Rent Condo Rent House
If you are currently renting, please complete the following fields:
Name of Landlord:			Home Phone:
Address:			Work Phone:

	Do you have a fenced yard on your property? Yes No
	If Yes, what type of fence?
	Wood Chain Link Other
	How high is the fence?
	How do you plan to allow your pet to relieve itself and/or exercise?
	Do all adults in the household work full time? Yes No
	Approximately how many hours each day will your dog be left alone?
	Where will the dog be kept when left alone?
	Do you have children living with you? Yes No
	If yes, what are their ages?
	What other animals do you have? List each: (include Breed, Age, Sex, Altered Status, Length of time with you)
	If you have had pets in the past, what happened to them?
	Under what circumstances do you believe a pet should not be spayed or neutered?
	Are there any restrictions on the number of dogs you may own where you live? Yes No
	If yes, how many are you allowed to have?
	Does anyone in your home have allergies to animals? Yes No
	Vet Reference
	Do you have a veterinarian now, or one that you have used in the past? Yes No
			Vet's Name:
			Address:
			Phone:
		Personal References (2)
		1.	Name:
			Address:
			Phone:
			Relationship:
		2.	Name:
			Address:
			Phone:
			Relationship:
		How did you hear about Affenpinscher Rescue?
		Affenpinscher Rescue Disclaimer
		There is absolutely no guarantee made or implied that any person requesting to adopt a dog being fostered through Affenpinscher Rescue, or posted on the Affenpinscher Rescue website, will be allowed to adopt a dog. Rather, all adoption applications are subject to acceptance based on a review process that may require collecting information from references and visiting the applicant's home. All decisions on placing dogs in adoptive and foster homes are based solely on the judgment of the volunteers and coordinators of Affenpinscher Rescue. Adoption applications submitted through this form may be denied for various reasons. Affenpinscher Rescue reserves the right to make all decisions regarding placement or final disposition of any rescued dog in its care whether in, or being placed in, a foster or adoptive home or other facility. By pressing the "Submit" button below you attest that you have read the above disclaimer and agree to the terms therein. Furthermore you represent that the information you have provided on this form is the truth to the best of your knowledge and belief.
Thank you for considering a rescue!