Applicants Name:     Applicants Age:  
Co-Applicants Name(s):     Co-Applicant(s) Age:  
Street Address:  
City:    State:     Zip Code:  
Daytime Telephone #:  
Evening Telephone #:  
Best Time To Contact You:  
E-mail:  
Who Will be the dog's primary caregiver (if not applicant)?:  
Relationship:  Spouse:  
Parent or Guardian:  
Other (explain):  
Will there be children living in the home with the dog?  
If so, how many?     Ages:   Gender:  
Is there anyone in the home who is allergic to dogs?:  
Is the pet for (check all that apply) an:   Adult   Child   Elderly person   Physically Challenged
How did you learn about our rescue?:  
Do you live in a (check one):   House   Townhouse   Apartment   Duplex   Mobile Home   Condo
Do you:   Own   Rent
Do you have the landlord's permission to have a dog over 50 pounds?:   Yes   No
Do you have a fenced yard:   Yes   No
Fence type and height:  
Where will the dog stay during the day?    Where will the dog stay during the evening? 
Is there anyone home during the day?    Who?  
Will your dog have the run of the house, be in blocked-off portions of the house, use a crate, be tied outside or live in the yard? Please be specific:  
Will your dog be allowed on the furniture or the bed?  
Is this your first dog?    
Please list all other pets in household: Name     Type     Age     Sex     Altered  
Have you ever sold, given away or surrendered a pet to a shelter?   Yes   No
If so, please describe circumstances:  
Do you plan to take an obedience course with your dog?   Yes No
Have you ever taken one?   Yes   No

Name and telephone number of veterinarian?  
May we contact him/her?  
I hereby authorize my veterinarian to release confidential information about my pets and my pet care.
Applicants Signature:  
Co-Applicants Signature:  

Age range interested in adopting: (Check all that apply)
Any Age   Puppy (0-2 years)   Adult   Senior (9+ years)
Preference:   Male   Female   No preference
Would you consider a dog mix?   Yes   No
Would you consider a special needs dog, such as one that requires medication for a permanent but controllable medical condition?   Yes   No
Have you applied to any other dog Rescues?   Yes   No
If yes, which one(s)?  

_________________________________________________________________________

In addition to your application please send us a detailed letter about yourselves and why you want to adopt a dog? Please include any information about special activities in which your rescue dog would be included. Also, if you have any special requirements for a dog, please let us know so we can carefully match the dog to its "forever home."

If, for any reason, the adopter should not be able to keep this dog, he/she is obligated to return the dog to dog Retriever Adoption, Placement & Education. The continuation of this program relies upon donations for medical and foster care for these homeless dogs. At the time of adoption, a non-refundable donation of $250 is appreciated. This money is used to help pay costs for homeless dogs who enter our program.

Adopters are not selected on a first come basis. We strive to choose the most compatible environment for our dog rescues. We reserve the right to refuse an adoption to any applicant. Adopters must be over 21 years of age.

I understand that by signing this contract, I am taking sole responsibility of the rescue dog. Golden Retriever Adoption, Placement & Education is not liable or responsible for any damage to persons or property once this contract is signed. I am signing and adopting the dog of my own free will and am not under duress of any kind. If the dog is being neglected or abused Golden Retriever Adoption, Placement & Education reserves the right to reclaim the dog.

Applicants Signature:  
Co-Applicants Signature:  

NOTE: Your application WILL NOT be processed until the application(Donation) fee is received.

You may apply online using paypal by clicking on the button at the bottom of the page or by mailing your application along with a non-refundable $25 application fee to:

GRAPE
PO Box 124
Springfield, PA 19064

You must submit the application, then submit the paypal.