1. Applicant Name *
2. Applicant Age *
3. Co-Applicant Name *
4. Co-Applicant Age *
5. Residential Address (not a P.O. Box) *
   Street address and City/State
6. City *
7. State *
8. Zipcode *
9. Home Phone *
10. Cel Phone *
11. Email *
12. Years at Residence *
13. Number of people in household *
14. Please list the number of children and individual ages in your home *
15. What large city is Closest to your home? *
16. What distance are you willing to travel to adopt (note: minimum of 250 miles or more may be required)? *
17. What age Bulldog are you willing to adopt? Please note we do not often get puppies in rescue unless they have a severity of health issues. *
    Puppy
    Up to 3 years
    Up to 6 years
    Any Age
    
18. Must the Bulldog be good with children? *
19. Are you willing to adopt a special needs Bulldog *
20. If yes or possibly, what level of special needs would you accept? *
    MINIMAL (Daily medications, special food, etc.)
    MODERATE (Frequent medications, house training issues, difficulty walking, behavior issues, etc.)
    SEVERE (Blindness, deafness, incontinence, seizure disorder, etc.)
    
21. Must the Bulldog get along with other dogs in your household and/or visiting dogs? *
22. Please list your occupation *
23. Please list your employer's address *
24. Annual Family Income *
25. Co-applicant's employer name *
26. Co-applicant's employer address *
27. Please list every member of your household including age and relationship *
    List each person on a different line please
28. Do children visit the home? *
29. Are you willing to supervise the Bulldog at all times with children under the age of 10 *
30. Is anyone in the household allergic to dogs? *
31. Who will be responsible for caring for the Bulldog? *
32. Are all household members in favor of adopting a Bulldog? *
33. Please describe your dwelling *
34. Do you own or rent? *
35. If condo, please list telephone number for condo association  
36. If rental, please list landlords name and phone number  
37. Do you have a fully enclosed fence? *
38. If you answered yes to the fence please describe it  
39. How will the dog be exercised, how often and who will supervise the dog while outdoors? *
40. Does your home have stairs that the Bulldog will have to go up and down? *
41. Please describe type of stairs and how many *
42. Do you have a swimming pool, pond (including ornamental ponds) in-ground hot tub, lake, river or any body of water in or near your residence? *
43. If you answered yes to the above question, is there a secure fence to keep the Bulldog out?  
44. Does your house have any doggie doors? *
45. If you answered yes describe how do you use the doggie door? *
46. Is your home air-conditioned? *
47. If you answered yes to the above question, what type (central/ room)?  
48. Is your car air-conditioned? *
49. What five words best describe your family? *
50. Please describe any changes you expect in your household in the next few years; e.g. new children, job changes, moving, etc. *
51. How soon will you be ready to adopt a Bulldog? *
    Immediately
    With in 3 months
    With in 6 months
    Longer than 6 months
    
52. Are any family members home during the day time *
    All Day
    Most of the day
    Part of the day
    Seldom
    
53. Are you involved in any pet store, commercial dog breeding operation or buying dogs for resale? *
54. Have you ever been convicted of cruelty to animals? *
55. Have you ever been suspended from a pure-bred dog association? *
56. Have you applied to adopt with any other rescue organizations? *
57. Have you ever owned a Bulldog? *
58. Do you currently own any dogs? *
59. Do you currently own any cats? *
60. Please list all pets (dogs, cats and others) owned now or in the past 5 years (Include type, breed, age and gender) *
61. Are they all spayed or neutered? *
62. Where are they now? *
63. Have you ever given a pet to a rescue organization or animal shelter? *
64. Have you ever had a dog that has bitten someone? *
65. Do all your pets get along with other animals?  
66. Do all your pets receive regular veterinary care (including heartworm testing and heartworm preventative) and are they up to date on vaccinations? *
67. What kind of flea/tick prevention do you use and how often do you administer it? *
68. What kind of Heart Worm prevention do you use and how often do you administer it? *
69. If you have adopted a rescue before, please provide details *
70. Client Name Listing for Current Veterinarian (if different from IEBR application name) *
71. Current Veterinarian Name *
72. Current Veterinarian Clinic Name *
73. Current Veterinarian Street Address, City, State, Zip *
74. Current Veterinarian Telephone Number *
75. Current Veterinarian Email Address, Website name *
76. PAST (5 years) Veterinarian Name *
77. PAST (5 years) Veterinarian Clinic Name *
78. PAST (5 years) Veterinarian Telephone Number *
79. PAST (5 years) Veterinarian Street Address, City, State, Zip *
80. PAST (5 years) Veterinarian Email Address, Website Name *
81. Are you willing to work with the rescued Bulldog to resolve problem behaviors (e.g. chewing, pulling on lead, barking, etc)? *
82. What type of behavior in a dog would make you not want to adopt him/ her? *
83. How will you correct behavior problems? *
84. Do you understand that rescued Bulldogs may have training problems, especially at first? *
85. Are you familiar with common Bulldog health problems? *
86. Please describe what you know about Bulldog health problems *
87. How much do you expect to pay per year to take care of a Bulldog? *
88. How much do you expect to pay per year in veterinary care to take care of a Bulldog? *
89. Who will care for the Bulldog during vacations or overnight trips? *
90. Can someone in the household provide daily care when the primary care giver is away? *
91. Do you have an emergency plan to provide care for your pets if you have to leave town suddenly? *
92. What do you feel is the proper use of crates or cages? *
93. Can all household members travel to the home of the rescue group's foster family to meet the prospective adoptee? *
94. Are you willing to take responsibility for the Bulldog for its lifetime? *
95. Do you agree to having a rescue volunteer inspect your home before and/ or after an adoption is completed? *
96. Please list the name and telephone number of two people (not in your household) that can verify your ability to take good care of a rescued bulldog *
97. All bulldogs adopted from IEBR will be spayed/ neutered before placement. Do you have any questions or reservations about this policy? *
98. Illinois English Bulldog Rescue has the right to refuse any placement with a potential adoptive home *
    I understand
    
99. Adoption Fees Are Non Refundable *
    I Understand
    
100. E-Signature *
101. Todays Date *
102. I understand that dogs placed by Illinois English Bulldog Rescue (IEBR) have been acquired fed and boarded by IEBR volunteers and have received necessary medical care and vaccinations; have been tested to be free of heartworms and contagious disease at the expense of IEBR, who receives financial reimbursement for expenses only through donations. I understand that I may be asked to give a donation to IEBR to help with the spaying/ neutering and veterinary care of current and/ future rescued Bulldogs *
     I Understand
     
103. Reload Image
     
104.  
     Please check the required fields

     

Your application has been received. Please give us two weeks to process.

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