<!-- Begin Freedback Form -->
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<form
enctype="multipart/form-data" method="post" action="
http://www.freedback.com/mail.php" accept-charset="UTF-8">
<div>
<input type="hidden" name="acctid" id="acctid" value="ob79tq7i4kfx8cv9"
/>
<input type="hidden" name="formid" id="formid" value="141675" />
<input type="hidden"
name="required_vars" id="required_vars" value="name,field-02d1097c144db8a,email,field-57da2d6cefb5dcb,field-61d5f112d498c86,field-92bafda63324afb"
/>
</div>
<table cellspacing="5" cellpadding="5" border="0">
<tr>
<td
valign="top">
<strong>Name of animal you are interested in?</strong>
</td>
<td
valign="top">
<input type="text" name="field-4aa5ae2f00f8b21" id="field-4aa5ae2f00f8b21"
size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Name:</strong>
</td>
<td
valign="top">
<input type="text" name="name" id="name" size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Address</strong>
</td>
<td
valign="top">
<input type="text" name="field-02d1097c144db8a" id="field-02d1097c144db8a"
size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Email Address:</strong>
</td>
<td
valign="top">
<input type="text" name="email" id="email" size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Marital Status?</strong>
</td>
<td
valign="top">
<select name="field-b92d99f3ff7c292" id="field-b92d99f3ff7c292">
<option
value="Single">Single</option>
<option value="Engaged">Engaged</option>
<option
value="Partnerd">Partnerd</option>
<option value="Married">Married</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>What is your occupation? </strong>
</td>
<td
valign="top">
<input type="text" name="field-795d5b12265f670" id="field-795d5b12265f670"
size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Spouse's name </strong>
</td>
<td
valign="top">
<input type="text" name="field-1eba2e3e3db62b3" id="field-1eba2e3e3db62b3"
size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Spouse's Occupation?</strong>
</td>
<td
valign="top">
<input type="text" name="field-d30b3529d882bc5" id="field-d30b3529d882bc5"
size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Daytime Phone Number, with area code </strong>
</td>
<td
valign="top">
<input type="text" name="field-193879a9b8aec20" id="field-193879a9b8aec20"
size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Evening Phone Number, with area code </strong>
</td>
<td
valign="top">
<input type="text" name="field-cccf298eb7312ef" id="field-cccf298eb7312ef"
size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>If you are under 21 years of age, what is your age? </strong>
</td>
<td
valign="top">
<input type="text" name="field-426d42fc3e3c3b0" id="field-426d42fc3e3c3b0"
size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Residence?</strong>
</td>
<td
valign="top">
<select name="field-cc1164d258fc0bb" id="field-cc1164d258fc0bb">
<option
value="Home">Home</option>
<option value="Apartment">Apartment</option>
<option
value="Condo">Condo</option>
<option value="Hobby Farm">Hobby Farm</option>
<option
value="Mobile Home">Mobile Home</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Do you Own or Rent?</strong>
</td>
<td
valign="top">
<select name="field-ed65ff0f95d0df2" id="field-ed65ff0f95d0df2">
<option
value="Own">Own</option>
<option value="Rent">Rent</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>If you Rent, do you have permission from your landlord to have a
dog? </strong>
</td>
<td valign="top">
<input
type="text" name="field-5982a2157b507c7" id="field-5982a2157b507c7" size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Landlords Full Name and Phone Number?</strong>
</td>
<td
valign="top">
<textarea name="field-8ffff1f819e60fc" id="field-8ffff1f819e60fc" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Are you planning on moving in the next year or so? </strong>
</td>
<td
valign="top">
<input type="text" name="field-b7333e7b714a842" id="field-b7333e7b714a842"
size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Personal Reference name and Number.</strong>
</td>
<td
valign="top">
<textarea name="field-293a4eae16ec7f8" id="field-293a4eae16ec7f8" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Relationship to applicant(s), how long have you known each other?</strong>
</td>
<td
valign="top">
<textarea name="field-41cedf960a036f7" id="field-41cedf960a036f7" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Would this be your first dog? </strong>
</td>
<td
valign="top">
<select name="field-aa97919928281c9" id="field-aa97919928281c9">
<option
value="Yes">Yes</option>
<option value="No">No</option>
<option
value=""></option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>What has been your experience with dogs? </strong>
</td>
<td
valign="top">
<select name="field-86670e5388e26e3" id="field-86670e5388e26e3">
<option
value="Had Growing up">Had Growing up</option>
<option value="Have had one">Have
had one</option>
<option value="Experienced">Experienced</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Describe your experience with dogs and what educational experience
you have had with dogs. Be specific (i.e. training classes, books, volunteering Etc.) </strong>
</td>
<td
valign="top">
<textarea name="field-4f1211efabbd298" id="field-4f1211efabbd298" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Do you have children under the age of 18 living in the household?
</strong>
</td>
<td valign="top">
<select
name="field-9541c84058b62a5" id="field-9541c84058b62a5">
<option value="Yes">Yes</option>
<option
value="No">No</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>If yes, list their names and ages.</strong>
</td>
<td
valign="top">
<textarea name="field-237de75c3bdef53" id="field-237de75c3bdef53" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>If you have children, what has been their exposure to dogs? </strong>
</td>
<td
valign="top">
<select name="field-af61bc427e4f06b" id="field-af61bc427e4f06b">
<option
value="None">None</option>
<option value="Some">Some</option>
<option
value="Allot">Allot</option>
<option value=""></option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Excluding children, spouse and applicant, list any other residents
living in the household Name and Relationship. </strong>
</td>
<td
valign="top">
<textarea name="field-fda0ce2ddb1a326" id="field-fda0ce2ddb1a326" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Is everyone living in the household aware of the decision to adopt
a dog? </strong>
</td>
<td valign="top">
<select
name="field-723d0c454bfaa7c" id="field-723d0c454bfaa7c">
<option value="Yes">Yes</option>
<option
value="No">No</option>
<option value=""></option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Who will be the person responsible for the daily care of the dog
such as feeding and exercise? </strong>
</td>
<td valign="top">
<textarea
name="field-50f183abc3ca551" id="field-50f183abc3ca551" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>What is the activity level of your household? </strong>
</td>
<td
valign="top">
<select name="field-7e39880714aff00" id="field-7e39880714aff00">
<option
value="Active">Active</option>
<option value="Quiet">Quiet</option>
<option
value="Very Active">Very Active</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Are you familiar with your local animal ordinances? (Number of pets
allowed in a household?) </strong>
</td>
<td valign="top">
<select
name="field-2100f39c1847686" id="field-2100f39c1847686">
<option value="Yes">Yes</option>
<option
value="No">No</option>
<option value="Unsure">Unsure</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Where will the dog be kept during the day when at work and/or away
for the day?</strong>
</td>
<td valign="top">
<select
name="field-4966f8f6a0e40a4" id="field-4966f8f6a0e40a4">
<option value="Loose in House">Loose
in House</option>
<option value="Crate in house">Crate in house</option>
<option
value="Basement">Basement</option>
<option value="Outside (chained)">Outside
(chained)</option>
<option value="Outside Kennel">Outside Kennel</option>
<option
value="Loose Outside">Loose Outside</option>
<option value="Fenced in Yard">Fenced
in Yard</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Where will the dog be kept during the night time?</strong>
</td>
<td
valign="top">
<textarea name="field-f4d27ab6cef68fd" id="field-f4d27ab6cef68fd" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>If planning to crate, how many hours will the dog be left alone
in the crate?</strong>
</td>
<td valign="top">
<input
type="text" name="field-9b9646c88ac64cf" id="field-9b9646c88ac64cf" size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Is your yard completely fenced? If yes, what type of fence? Height?
</strong>
</td>
<td valign="top">
<textarea
name="field-4854c1f62f20bfd" id="field-4854c1f62f20bfd" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Do you plan on fenceing in your yard in the future?</strong>
</td>
<td
valign="top">
<select name="field-4d6cd81bc752f5b" id="field-4d6cd81bc752f5b">
<option
value="Yes">Yes</option>
<option value="No">No</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>If not, how will you confine the dog to your property?</strong>
</td>
<td
valign="top">
<textarea name="field-6aa31ef88a96381" id="field-6aa31ef88a96381" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>List all forms of exercise the dog would receive. </strong>
</td>
<td
valign="top">
<textarea name="field-fe17404ce86941c" id="field-fe17404ce86941c" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Are you interested in an indoor or outdoor dog? If Both Explain.</strong>
</td>
<td
valign="top">
<textarea name="field-e2e9acdf3e5e199" id="field-e2e9acdf3e5e199" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Please provide a description of how you would correct your new puppy/dog
if it showed destructive or inappropriate behavior such as digging, jumping, chewing, and etc. </strong>
</td>
<td
valign="top">
<textarea name="field-f2d3e580cb34747" id="field-f2d3e580cb34747" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Are you planning to attend basic dog obedience classes? </strong>
</td>
<td
valign="top">
<select name="field-e7c6feb4762464c" id="field-e7c6feb4762464c">
<option
value="Yes">Yes</option>
<option value="No">No</option>
<option
value="Unsure">Unsure</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Are you willing to pay for and attend canine obedience classes if
necessary to eliminate problems cited as reasons for behavioral issues? </strong>
</td>
<td
valign="top">
<select name="field-7929adbe8d7bdaf" id="field-7929adbe8d7bdaf">
<option
value="Yes">Yes</option>
<option value="No">No</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>List all of the pets you have owned in the past 7 years, If you
no longer have them what happened to them?</strong>
</td>
<td valign="top">
<textarea
name="field-04d9a709d2e2bd7" id="field-04d9a709d2e2bd7" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Do you have any current pets? List breeds and ages.</strong>
</td>
<td
valign="top">
<textarea name="field-033503664a29ca4" id="field-033503664a29ca4" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Have your own pets been introduced to other animals? If yes, how
did they react? </strong>
</td>
<td valign="top">
<textarea
name="field-b65fdfc99a43cc1" id="field-b65fdfc99a43cc1" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Do you understand the steps required to properly introduce your
new dog to the other animals currently living in your home? </strong>
</td>
<td
valign="top">
<select name="field-7106eeb4bd0c68e" id="field-7106eeb4bd0c68e">
<option
value="Yes">Yes</option>
<option value="No">No</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Did your pets, previous or current, receive annual veterinary care?
</strong>
</td>
<td valign="top">
<select
name="field-ea5158834c05192" id="field-ea5158834c05192">
<option value="Yes">Yes</option>
<option
value="No">No</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Are your current pets UTD with vaccinations?</strong>
</td>
<td
valign="top">
<select name="field-56d45fa9f53e4e4" id="field-56d45fa9f53e4e4">
<option
value="Yes">Yes</option>
<option value="No">No</option>
<option
value="Unsure">Unsure</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Are your current dogs tested yearly for Heartworms and on monthly
preventative? If No explain why.</strong>
</td>
<td valign="top">
<textarea
name="field-315e71126c7ce5b" id="field-315e71126c7ce5b" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>List Name of and number of vet clinic you are currently using.</strong>
</td>
<td
valign="top">
<textarea name="field-7f6ec5d51a01c2a" id="field-7f6ec5d51a01c2a" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Whose name is listed on the account? </strong>
</td>
<td
valign="top">
<input type="text" name="field-230c1d4ec7203f1" id="field-230c1d4ec7203f1"
size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>If you do not have a vet list vet you have used in the past or plan
on using in the future. </strong>
</td>
<td valign="top">
<textarea
name="field-8d1b6d00e07a108" id="field-8d1b6d00e07a108" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Are you aware of the annual routine vaccinations recommended for
the health and protection of dogs? </strong>
</td>
<td valign="top">
<select
name="field-7495d60435cf628" id="field-7495d60435cf628">
<option value="Yes">Yes</option>
<option
value="No">No</option>
<option value="Unsure">Unsure</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>How much do you think it will cost to take care of this animal each
year? (Food, supplies, vet bills, major medical care if needed, etc.) </strong>
</td>
<td
valign="top">
<input type="text" name="field-7c325fc54fbe95f" id="field-7c325fc54fbe95f"
size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Are you prepared financially for emergency medical and/or major
medical care for the pet? Please be aware that emergency and major medical care needed for dogs can be expensive. </strong>
</td>
<td
valign="top">
<select name="field-65534ffc9e186b1" id="field-65534ffc9e186b1">
<option
value="Yes">Yes</option>
<option value="No">No</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>How many hours will the dog be left alone? </strong>
</td>
<td
valign="top">
<input type="text" name="field-bd963e658991a9b" id="field-bd963e658991a9b"
size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>On the average, how many evenings per week do you spend at home?
</strong>
</td>
<td valign="top">
<input
type="text" name="field-a64cb3c9549851c" id="field-a64cb3c9549851c" size="40" value="" />
</td>
</tr>
<tr>
<td
valign="top">
<strong>Are you and/or your family frequent travelers? If Yes Please explain.</strong>
</td>
<td
valign="top">
<textarea name="field-fd1047077db8e85" id="field-fd1047077db8e85" rows="6"
cols="40"></textarea>
</td>
</tr>
<tr>
<td
valign="top">
<strong>What activity level are you looking for in a dog?</strong>
</td>
<td
valign="top">
<select name="field-fa3249cabd2fc9c" id="field-fa3249cabd2fc9c">
<option
value="Calm">Calm</option>
<option value="Lap dog">Lap dog</option>
<option
value="Semi-active">Semi-active</option>
<option value="Active">Active</option>
<option
value=""></option>
<option value=""></option>
<option
value=""></option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Do you know if anyone living in the household is allergic to dogs?
</strong>
</td>
<td valign="top">
<select
name="field-73db35c287d1e7e" id="field-73db35c287d1e7e">
<option value="Yes">Yes</option>
<option
value="No">No</option>
<option value="unsure">unsure</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>If yes, and someone living in the household IS allergic to dogs,
is that person currently on allergy medications? </strong>
</td>
<td
valign="top">
<select name="field-e304cb3d8672fb5" id="field-e304cb3d8672fb5">
<option
value="Yes">Yes</option>
<option value="No">No</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>What are your reasons for adopting a dog? Check all that apply.</strong>
</td>
<td
valign="top">
<input type="checkbox" name="field-40fc356a57e5a18[]" id="field-40fc356a57e5a18[]"
value="Companion for me" /> Companion for me<br/>
<input type="checkbox" name="field-40fc356a57e5a18[]"
id="field-40fc356a57e5a18[]" value="Companion for other pet" /> Companion for other pet<br/>
<input
type="checkbox" name="field-40fc356a57e5a18[]" id="field-40fc356a57e5a18[]" value="Companion for Children" /> Companion
for Children<br/>
<input type="checkbox" name="field-40fc356a57e5a18[]" id="field-40fc356a57e5a18[]"
value="House pet" /> House pet<br/>
<input type="checkbox" name="field-40fc356a57e5a18[]"
id="field-40fc356a57e5a18[]" value="Gift" /> Gift<br/>
<input type="checkbox" name="field-40fc356a57e5a18[]"
id="field-40fc356a57e5a18[]" value="Watchdog" /> Watchdog<br/>
<input type="checkbox"
name="field-40fc356a57e5a18[]" id="field-40fc356a57e5a18[]" value="Guard Dog" /> Guard Dog<br/>
<input
type="checkbox" name="field-40fc356a57e5a18[]" id="field-40fc356a57e5a18[]" value="Personal Protection" /> Personal Protection<br/>
<input
type="checkbox" name="field-40fc356a57e5a18[]" id="field-40fc356a57e5a18[]" value="Hunting" /> Hunting<br/>
<input
type="checkbox" name="field-40fc356a57e5a18[]" id="field-40fc356a57e5a18[]" value="" /> <br/>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Although every animal admitted to Heavenly Hearts Rescue has been
provided with a wellness exam by a veterinary clinic prior to adoption, we cannot guarantee the health of every animal, nor
can we be held responsible for his or her behavior after adoption</strong>
</td>
<td
valign="top">
<select name="field-1f88d34f06d03f4" id="field-1f88d34f06d03f4">
<option
value="I understand and agree">I understand and agree</option>
<option value="Do
not understand or agree">Do not understand or agree</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>If for any reason you are unable to keep the pet, health reasons
or otherwise, adopter is required to contact HHR for the prompt return of the animal without making any charges of any kind
for any liabilities. If you need to return the pet for health reas</strong>
</td>
<td
valign="top">
<select name="field-570022b9b473c73" id="field-570022b9b473c73">
<option
value="I understand and Agree">I understand and Agree</option>
<option value="I
do not understand or agree">I do not understand or agree</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>If you are not prepared to handle behavior issues that may arise,
it is in your best interest (and the animals) to postpone adoption at this time. Should you decide to postpone the adoption
at this time, or take some time to reconsider, HHR understands yo</strong>
</td>
<td
valign="top">
<select name="field-7a52d85fd326a24" id="field-7a52d85fd326a24">
<option
value="I am ready to adopt">I am ready to adopt</option>
<option value="Please
keep my application for a later adoption">Please keep my application for a later adoption</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>I HAVE READ THE ABOVE STATED APPLICATION CAREFULLY AND CERTIFY THAT
THE INFORMATION I HAVE GIVEN IS ACCURATE AND TRUE. I UNDERSTAND THAT OMISSION OF INFORMATION AND/OR FAILURE TO ANSWER ALL
QUESTIONS AND SIGN THE APPLICATION CAN RESULT IN THIS APPLICATION</strong>
</td>
<td
valign="top">
<select name="field-57da2d6cefb5dcb" id="field-57da2d6cefb5dcb">
<option
value="I have read and agree with policies.">I have read and agree with policies.</option>
<option
value="I have read and disagree with the policies">I have read and disagree with the policies</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>The Adopter agrees, in the interest of safety, to never leave young
children unsupervised with the animal. The Adopter agrees that the adoption of a companion animal conveys with it a responsibility
to care for the well being of the animal for the duratio</strong>
</td>
<td
valign="top">
<select name="field-61d5f112d498c86" id="field-61d5f112d498c86">
<option
value="I have read above policy's and agree">I have read above policy's and agree</option>
<option
value="I have read above policies and disagree.">I have read above policies and disagree.</option>
</select>
</td>
</tr>
<tr>
<td
valign="top">
<strong>Thank you for taking the time to fill out and read this form, at
time of adoption I understand that I will have to sign adoption contract and any other forms to complete the process. We will
contact you shortly..</strong>
</td>
<td valign="top">
<select
name="field-92bafda63324afb" id="field-92bafda63324afb">
<option value="I understand
and agree">I understand and agree</option>
<option value="I disagree">I disagree</option>
</select>
</td>
</tr>
<tr>
<td
colspan="2" align="center">
<input type="submit" value=" Submit Form " />
</td>
</tr>
</table>
</form>
