*Indicates a required field:
Applicant Name*:
Applicant Age:
Co-Applicant Name:
Co-Applicant Age:
Relationship of applicant and co-applicant:
Names and ages of all other human members of the household*:
If you do not have young children living in your home, will your adopted dog come into regular contact with children under the age of ten, such as grandchildren, neighbors, etc.?*	Yes No
If yes, please indicate ages of children and anticipated frequency of contact:
Are you applying for our Seniors 4 Seniors Program?	Yes No
Home Address Line 1*:
Home Address Line 2:
City*:
State*:	Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia 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
ZIP*:
County:
Home Phone*:
Work Phone:
Cell Phone:
E-mail*:
Applicant's Occupation:
Co-Applicant's Occupation:
How should we contact you?	Home Phone Work Phone Cell Phone Email
When is the best time to contact you?	Morning Afternoon Evening Anytime
How did you learn about DVGRR?	Internet Search Friend/Family Meet & Greet the Goldens Day Volunteered Other
If Friend/Family, please provide their name, if Other, please describe:
Have you previously adopted from DVGRR?*	Yes No
If yes, please enter dog's name and tag number:
Why do you want to adopt a rescued Golden Retriever? Please be as specific and detailed as possible*:

Home Environment - Step 2
What type of home do you reside in?*	Single Family House Townhouse/Condo Apartment Duplex Other
If other, please describe.
Do you own or rent your home?	Own Rent
If renting, do you have written permission from your landlord to have a dog over 50 lbs?	Yes No
Will the dog regularly be taken to any other family residences, such as a weekend or vacation home?	Yes No
If yes, please describe the frequency of visits and type of home/yard.
Do you have any dog doors in your home leading to the outside yard?	Yes No
If yes, will the dog have access to these when you are not home?	Yes No
Is your lawn chemically treated?	Yes No
If yes, please describe.
Please list all other current pets in your household. Indicate type, breed, age, and whether spayed or neutered*:
Please describe how your pets get along with dogs.
For applicants with no current dogs: Will your adopted dog(s) interact regularly with dogs belonging to other family members, friends, neighbors, etc.?*	Yes No
If yes, please describe.
Does anyone in your household have allergies to animals?	Yes No
If yes, please describe.
Does anyone in your household have a physical disability or serious health condition(s)?*	Yes No
If yes, please describe.
Who will be primarily responsible for the care of the adopted dog?*
Is anyone regularly at home during the day?	Yes No
If yes, please describe who and how often.
How long on average will the dog be alone (without humans) during the day?*	0-2 hours 3-4 hours 5-6 hours 7-8 hours 8-9 hours 10 or more hours
Will your dog have the run of the entire house?	Yes No
If no, please describe areas your dog will and will not have access to and reason for restriction:
Where will your dog sleep at night?	Wherever He or She Would Like Crate Downstairs Only Other
If Other, please describe.
Will your dog ever be kept in the basement or garage?*	Yes No
If yes, please explain frequency and circumstances.
Will your dog ever live outside in a yard or outdoor kennel?*	Yes No
If yes, please describe.
Will your dog ever be tied outside?*	Yes No
If yes, please describe.

Fence Information - Step 3
Do you have a physical or electronic (invisible) fence that completely encloses part, or all, of your yard?*	Physical Fence Electronic (invisible) Fence No Fence
If you do not have a fence, you MUST request an exemption at the bottom of this section. If you have a fence, please complete the following details.
If Physical, describe fence material: If Electronic, describe manufacturer and installer:
Fence height (for Physical):	ft
Area that is enclosed:	Entire front and back yard Front yard only Back yard only Other (describe)
If Other, please describe:
Approximate dimensions of fenced area (length, width OR acreage)	ft ft acre(s)

Fence Exemption Request - Step 4
If requesting an exemption to the fenced yard requirements, please include a detailed statement below describing your circumstances, lifestyle, previous dog ownership, and how you plan on safely exercising and managing an adopted Golden Retriever while still complying with DVGRR's Terms and Conditions of Adoption. Exemption requests from first time dog owners will not be considered. Please remember that we primarily place only senior, less active, or special needs dogs into homes without a fenced yard.

Animal Ownership and Experience - Step 5
Will this be your first dog?*	Yes No
Will this be your first Golden Retriever?*	Yes No
Have you ever sold, given away, or surrendered a pet to a shelter?*	Yes No
If yes, please describe circumstances.
Have you ever had a pet die because of age, illness, accident, or euthanasia?	Yes No
If yes, please describe:
Have you ever bred a dog?	Yes No
If yes, please describe circumstances:
Do you plan to breed dogs?*	Yes No
If yes, please describe:
Are you familiar with the use of a dog crate to train and/or confine the dog while he or she is unsupervised?	Yes No
If yes, have you used a crate with a previous dog?	Yes No
If your adopted dog requires it, are you willing to crate train and use a crate?	Yes No
What type and brand of food do you currently use (or have you used in the past) for your dogs?*
If DVGRR recommends using a higher quality food for your adopted dog, are you able and willing to make that change?	Yes No
If no, please explain:
Do you plan to groom the dog yourself, use a groomer, or both?	Groomer Myself Both
Will your dog be walked daily?	Yes No
If yes, approximately how many times and how far?
Will the dog be exercised in a fenced yard?	Yes No
If yes, by whom and how often?
What other kind(s) of exercise or activities will your dog participate in?
Will your dog ever be allowed to run or play off leash in unfenced areas?*	Yes No
If yes, please describe:
How do you plan to train your dog to be a well-mannered member of the family? Please be as specific and detailed as possible.*
Have you or a family member ever completed an obedience course with another dog?	Yes No
If yes, please indicate how long ago and what kind of training:
Describe any other previous experience you or a family member has had in training dogs:
Have you or a family member ever participated in any dog-related activities such as conformation, obedience, agility, flyball, animal-assisted therapy, etc.?	Yes No
If yes, please describe:
Are you aware that routine costs of maintaining a dog average $800 to $1,200 per year?	Yes No
If your adopted dog develops a serious illness, injury, or health condition at some point in his or her life, are you prepared to obtain necessary/appropriate medical care?	Yes No
If no, please describe limitations you anticipate:
If your adopted dog develops a serious behavioral or training problem at some point in his or her life, are you prepared to obtain necessary/appropriate training or behavior consultation?	Yes No
If no, please describe limitations you anticipate:

Golden Retriever Breed Information and Preferences - Step 6
Are you aware that Golden Retrievers are very active dogs (especially when young) and will require significant daily exercise and ongoing training?	Yes No
Are you aware that Goldens shed year round?	Yes No
Are you aware that Golden Retrievers are large dogs and may jump and knock down children or the elderly?	Yes No
Do ALL members of the family want to adopt a Golden Retriever?*	Yes No
Some Goldens are accustomed to being allowed on furniture, others are not. For placement information purposes, will your dog be allowed on the bed or other furniture?	Yes No
The Goldens in our program range considerably in age. Please identify the age range you are primarily interested in adopting:*
Do you prefer a male or female Golden?*	Male Female No Preference
Would you consider adopting a senior Golden?*	Yes No Possibly
Would you consider adopting a pair?*	Yes No Possibly
Would you consider adopting a Golden mix?*	Yes No Possibly
For applicants with no current dogs: Would you consider adopting a dog who does not get along well with other dogs? (We get many wonderful dogs in our program who need to be an “only dog.”)*	Yes No Possibly
Would you consider adopting a special needs dog, such as one with physical or sensory impairments or who requires medication for a permanent but controlled condition?*	Yes No Possibly
If yes, please describe what types of medical conditions would be acceptable to you:
What is your anticipated time frame for adopting a dog? (We will not hold you to your reply; it is just to assist us in the planning and matching process.)*	I am ready immediately Within the next several weeks or months Not sure, just want to be on the approved list Other
If Other, please describe:
ADDITIONAL INFORMATION: We encourage you to provide additional information about yourself and your family, including any special activities in which your DVGRR dog would be included. Also, if you have any special requirements or requests for a dog, please let us know so that we can more carefully match a dog to your lifestyle. The more we know about you, your family, and your pets, the better!

Veterinarian Information Request - Step 7
In order to complete your application, we will also need a reference from your veterinarian. The form to use can be found here. Please have your veterinarian complete the form and submit online OR he/she can print the form to mail or fax to us. Whatever option is used, forms must come directly from the veterinarian's office. If you have no current pets but a veterinarian has treated former pets of yours in the recent past, please send the form to that vet. Please let your vet know that the application may be held up if we do not receive the completed form back promptly.
I hereby authorize my veterinarian(s) to release confidential information about my pets and my pet care.
I do not have a current or former pet, and have NEVER used a veterinarian.
Veterinarian's Name:
Address:
Phone Number:

DVGRR Policies - Step 8
Are you able and willing to comply with DVGRR's requirement that an adopted dog must NEVER be off leash except in securely fenced areas? You can read more about this policy here as well as in our Terms and Conditions of Adoption. Please understand that this policy is in effect for the entire duration of the dog's lifetime, not just in the beginning or until you feel the dog is trained.*	Yes No
If No, please explain:
Are you able and willing to comply with DVGRR's requirement that you must take your adopted dog through a group or individual obedience class within 90 days of adoption (unless waived by Adoption Manager)?*	Yes No
If No, please explain:
I/we understand and accept the following ADOPTION FEES (do not send now): - Puppies up to 4 months old: $750 - Dogs 4 months to 8 years old: $550.00 (one dog) - Dogs 4 months to 8 years old: $995.00 (two dogs) - Dogs 9 to 12 years old: $325.00 - Dogs 13 and over or Special Needs: $100.00 To read more about how are adoption fees are determined, please click here.
I/we understand that DVGRR's adoption matchmaking process involves mutual decision-making between the adopter and Adoption Team and is based on determining which family or individual can best meet the needs of each dog in the program. DVGRR's Adoption Team will take my/our preferences regarding age, activity level, etc. into consideration but cannot guarantee that I/we will be matched with a dog meeting those specific criteria.
I/we attest that I have read and understood the Eligibility Requirements for adopting from DVGRR.
I/ we attest that the Terms and Conditions of Adoption have been read in full by me/us and I/we agree to abide by the rules set forth in them. I/we understand that these Terms and Conditions of Adoption are part of the adoption process and will be enforced. I/we also agree to allow a DVGRR representative to visit my/our home by appointment.
Applicant's Digital Signature:
Date:
Co-Applicant's Digital Signature:
Date: