Contact Information Name of applicant:  * Name of co-applicant:  * Email address:  * Home phone: Cell phone: Address: City: State: Zip code: Applicant occupation and work schedule:  * Co-applicant occupation and work schedule:  * Best time to contact you?  *   Preliminary Information Are you aware that routine costs to maintain a dog average $1000 per year? Yes No Are you aware that a minimum donation of $250 ($300 for puppies under 6 months) is required for adoption? Yes No How did you learn about GRRH?   New Family Information Please list all members of your household (excluding pets). Indicate names & ages.  * Please list all pets (dogs cats bird etc.) of your household (names ages breeds genders).  * Are all of your pets spayed and/or neutered? If no please indicate the status for each pet.  * Are all dogs in your household on regular year-round heartworm preventative? Yes No N/A Other than children living in the household will your Golden come into contact with any children under the age of 5 years (e.g. grandchildren neighbors etc.)? If so how often and what ages?  * Do any elderly or physically challenged family members live with you or visit frequently? Yes No   Home Environment What type of dwelling do you live in? House Apartment Condo/Townhome Trailer Do you rent or own? Rent Own If you rent may we contact your landlord? Please provide name and contact information. Do you have a fenced yard? If yes what type and height of fence?  * Do you have a dog door? Yes No   Your History With Pets Will this be your first dog? Yes No Will this be your first Golden? Yes No What other breed of dogs have you been the caregiver for?  * If a pet has died that has resided in your household within the last 15 years please explain when at what age and under what circumstances. Please include an explanation for each pet that has died. Have any of your dogs had heartworm? Yes No N/A Have you ever bred a dog? Yes No Have you ever sold a pet? Yes No Have you ever given a pet away? Yes No Have you ever surrendered a pet to a shelter? If yes please explain the circumstances.  *   Care of Your Golden Do all members of the family want a Golden? Yes No Why do you want a Golden?  * Why do you think you would be a good caregiver for a Golden?  * What age Golden fits with your lifestyle and expectations? Please explain.  * Describe the characteristics you would like your Golden to have.  * Are you aware that Goldens are very active? Yes No Are you aware that Goldens shed year-round? Yes No Are you aware that Goldens are large dog and may jump up on children and the elderly? Yes No Is there anyone in your home who may be adversely affected by dogs (e.g. due to allergies)? If so please explain.  * Who will care for train and exercise the dog?  * How will you provide exercise for your Golden?  * Describe activities in which your Golden would be included (e.g. family outings swimming etc.)  * Is anyone home during the day? If so who and what age?  * How long will the Golden normally be left alone each day?  * Where will the Golden be kept during the day when no one is home?  * When you transport/travel with your Golden will it ride in a car truck or both? Car Truck Both If you answered either "Truck" or "Both" above how will you restrain your Golden to keep him/her from jumping from or being tossed out of the vehicle? What provisions have you made for your dog's care if you should get sick or hospitalized?  * What will happen to the dog if you get married have children or divorced?  * If you move what will you do with your dog?  * What will you do with the dog when you are traveling for business or pleasure?  * Will your dog... Have the run of house Be blocked-off in parts of the house Be crated Be tied outside Live loose in fenced yard Live in a dog run Allowed to roam loose Are you familiar with the use of a dog crate for ...training? ...safety during your absence? ...assisting in housebreaking? ...providing a haven at night? Yes No Are you willing to use a crate? Yes No Where will your Golden sleep at night? Are you willing to... Have your dog attend formal obedience class? Consult an expert for solutions to behavioral problems? Pay for one-on-one training if needed? Will you groom the Golden yourself or use a grooming service?  * Are you familiar with state county and local dog laws and willing to follow them? Yes No   Golden Preferences Would you consider a special needs dog such as one who requires medication for a permanent but controlled condition? Yes No Possibly Do you prefer a male or female Golden? Male Female No preference If you are interested in a specific Golden that you saw on our website please indicate the name(s).   Post-Application Process May we visit your home prior to application approval? Yes No Please indicate the best day of the week and time during the day that you and your family would be available for a home visit.  * May we contact your veterinarian? If so provide name and contact information of your vets' most recent addresses and phone numbers.  * Our volunteers may take 2 weeks or more to complete the application process. Are you willing to wait? Yes No   NOTICE: Answers are expected to be complete and truthful as they will enable us to be more familiar with your request and requirements and will help us find the Golden Retriever which best matches your needs and expectations. Failure to supply accurate information can result in revocation of the adoption at any time by GRRH. By completing this form the undersigned(s) expressly give permission to GRRH to verify the information contained in this Application and further release GRRH from any and all liability associated with this Application or with the adoption of a dog through GRRH.   I/We attest that the Terms and Conditions of Adoption as stated above have been read in full by me/us and I/we understand that these terms constitute a part of the adoption agreement between me/us and GRRH and will be enforced.   I/we attest that the information provided on this application is true and accurate to the best of my/our knowledge. I/we attest that we have retained a copy of the Adoption Requirements and also understand that completion and submission of this application does not guarantee adoption of a Golden Retriever. (If application is sent electronically I/we further attest that no changes have been made to the content of this document. I/we understand that approval by signature is assumed and agree to transmit a signed original (or facsimile copy thereof) prior to any decision by GRRH on my/our adoption application.)   Name of applicant  * Date  * Name of co-applicant  * Date  * Do not enter anything in this field: