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ADOPTION APPLICATION
Golden Moments Rescue
(Print out this form)
Complete, Sign & Send To:
Athena Brown
2003 Sage Road
Casper, WY 82604-1867

PERSONAL INFORMATION

Name of Applicant:
______________________________________________________________

Name of CO-applicant (adults over 18 yrs. only):

______________________________________________________________

Relationship to Applicant:
______________________________________________________________

Address:_______________________________________________________

City, State, Zip:________________________________________________

Phone: Home (____)________________ Work (____)_________________

E-mail______________________________________________________

Applicant's Employer Job Title:
_____________________________________________________________

How did you hear about Golden Moments Rescue?_______________________________________________________
DOG PREFERENCES
(This information will guide us in finding the Golden best suited to your
situation. Applicants should understand that the more latitude
indicated here, the higher the potential for finding a dog in the shortest
period of time).

Sex________ Prefer:____ Require:_____ If you answered "require,"
please explain:
______________________________________________________________

AGE________ Prefer:_____ Require:_____ If you answered "require,"
please explain:
______________________________________________________________

Would you consider a dog:

Older than 3 years? _____Older than 5 years? ______
Please list, in order of importance, the attributes you are seeking in a
dog:
a._____________________________________________________________

______________________________________________________________

b._____________________________________________________________

______________________________________________________________

c._____________________________________________________________

______________________________________________________________

1. Please explain why you want to adopt this animal:
______________________________________________________________

______________________________________________________________

HOUSEHOLD & DOG CARE INFORMATION  (circle one)

Do you live in a: House   Townhouse   Apartment   Duplex   Condo

Do you: Own  Rent

Do you have a fenced yard? Yes    No

What type of fence?
______________________________________________________________

If you do not have adequate fencing (i.e., a totally enclosed, secure
fence), how will you provide exercise for the dog?__________________________________________________________

How many adults in household?_____ Children?_____ Ages:________

Who will be responsible for the care of this pet?_____________________

______________________________________________________________

Where would the pet be kept during the day?_____________________

______________________________________________________________

Signature of Applicant:

_______________________________________Date___________________

Signature of CO-Applicant:

_______________________________________Date___________________