PART 1: Contact and personal Information

The fields with a * must be completed or the form won't go through.

1. * First Name:

2. * Last Name:

3. * Street Address:

4. * City:

5. * Zip Code:

6. Home Phone #

7. Work Phone #

8. * Select State or Province: Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territory Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Other

9. * E-Mail:

10. * How old are you? 13 or Less 14 to 17 18 to 20 21 to 25 26 and older

11. Occupation:

12. Do you live with:   Spouse/partner   Roommate(s)   Parents   Alone

13. How many adults (21 and older) in your household?

14. How many individuals under 21 in your household?

15. What are the ages of the individuals under 21?

16. How far could you drive to pick up a dog?

17. If needed, would you pay for or assist with shipping expenses? YES   NO

PART 2: Liability and responsibility

The following three (3) questions must be answered or your application won't be considered. Note that the caretakers of any dog listed in PBRC may have their own contract and/or require additional release waivers.

18. * By checking YES you agree to absolve PBRC and all of its representatives from any liability in reference to a dog featured in this web site. YES   NO

19. * By checking YES you agree that the dog will not be used in any illegal activities nor be found at any time in a municipality where Pit Bull presence is illegal. YES   NO

20. * By checking YES you agree that the dog is to be kept as a house pet. It shall not be sold for medical or experimental purpose, and it shall not be used for breeding. YES   NO

PART 3: Dog(s) you are interested in adopting

After you visited the LIST of available prospects for adoption, please provide the name and ID number of the dog(s) you are interested in adopting [Ex: Max (#12345)]. If we do not have the dog's name as well as ID number, we will be unable to process your application.

21. Choice#1 (required)

22. Choice#2 (optional)

23. Choice#3 (optional)

24. Choice#4 (optional)

25. * Are you looking for a:  Male   Female   Either

26. Do you prefer a:  Puppy   Adult   Either

27. If you have a preference in color and weight, please describe it here:

28. Prefer dog to be: (check all that apply)
Already spayed or neutered
Not spayed or neutered
Doesn't matter

29. Additional requirements about the dog you would like to add:

PART 4: Living situation and lifestyle

30. Dog's living situation (check all that apply)
Dog will be house pet, living inside with family
Dog will live in basement or garage
Dog will live outdoors
Doghouse provided
Guard Dog for: Business   Residence
Other - please specify:

31. How many hours a day will dog be home alone?

32. When home alone dog will be (check all that apply):
In a crate, wire cage, or dog pen inside  
In a Kennel:   Outdoor   Indoor   Both
Tied up outside:   Cable Run   With a chain
Dog will be loose:   Indoor   Outdoor
Other - please specify:

33. How will you exercise the dog? (check all that apply)
Leash walks every day
Will have cable or dog run in the yard
Will be free to run in fenced yard
Will have supervised access to unfenced yard
Will be free to roam around (Off leash and unsupervised in unfenced area)
Will bring to dog park (Public area where dogs can run and play together off-leash)
Other:

34. Is the home in an Urban Suburban Rural setting?

35. Yard size is: Small   Medium   Large   Acreage   No Yard

36. Is the yard enclosed by a fence? YES   NO

37. If so, height, length, and type of fence:

38. Do you live in a House   Apartment ?

39. Do you own the property? YES   NO

40. If you are renting, please provide Landlord's name and phone number for verification:

41. Does your municipality have breed specific restrictions?
YES   NO   Don't know

42. If so, please describe the nature of the restrictions:

IMPORTANT: Many homeowner's insurance companies have breed blacklists which include, but are not limited to, pit bulls, American Pit Bull Terriers, American Staffordshire Terriers, Staffordshire Bull Terriers, Rottweilers, Dobermans, Akitas, American Bulldogs, Chows and wolf-hybrids and will not insure you if they reside in your home or may cancel your insurance if you add a dog of these breeds to your home. Please check your homeowner's insurance policy regarding breed discrimination BEFORE adopting a pit bull type dog. Landlords may also have these same breed restrictions due to their insurance policies.

PART 5: Other Pets and experience

43. Do you have other DOGS? (Check all that applies)
No other dogs
One or more spayed female
One or more neutered male
One or more UNspayed female
One or more UNeutered male

44. Please specify breeds and ages of other dogs:

45. If you had other dogs in the past, please let us know their current disposition:
Still have the dog(s)
Died of old age fatal disease
Gave or sold to friends, relatives or acquaintance
Was hit by a car
Was stolen
Disappeared/Lost

46. Please specify what happened.

47. What other kind of animals do you own?

 
48. Of all the breeds available why do you want a Pit Bull ?

 
49. Experience: Please relate any prior experience you have had with this breed:

50. * References: Please supply the name and phone number of your current veterinarian, or the one who saw your previous pet(s), with their title identification. If you don't have a vet, please provide the name of your employer, clergyman, or anyone not related to you who can attest to your character. Vet references are preferred.

 
51. Additional information you would like to provide about yourself and/or the dog you would like to adopt:

Please review ALL the information provided before you click submit.