Many Miles Home Dog Rescue
Dog Name___________________________
87295 Territorial Highway
Veneta, OR 97487
Microchip Number__
his form and consultation with MMH is designed to help you find the dog most compatible with your
life style. Completion of this adoption application does NOT guarantee adoption of a Many Miles dog.
Please attach photos of your back yard. Including fencing type and entrances/exits.
(Or email to
In o
rder to be considered as an adopter you must:
1. Be 21 years of age or older.
2. Have a valid driver’s license or other government issued ID.
3. Have proof of the knowledge and consent of your landlord if renting.
4. Be willing and able to provide proper care, training and medical treatment to adopted dog.
Street Address: __________________________________________________________________
City: _____________________________ State: ________________________
Secondary Phone: ____________________________________________
Email Address: _______________________________________________
Number of adults in household________ Number of children________ Ages of children______________
ho will be the primary care giver for your new dog? ____________________________
Are you currently pregnant or hoping to be in the near future? Yes or No
Have y
ou considered the time/attention a new dog/puppy will require? Yes or No
often have dogs returned when someone becomes pregnant. That is why we ask)
What type of housing do you reside in? House apartment condo other: ____________________
Do you own or rent? ___________ Landlords name and Phone: _________________________________
Do you have a completely fenced yard? _________ What type of fencing? __________ Height: ________
Why do you want a dog? ________________________________________________________________
What qualities are you looking for in your new dog?
Office Use Only:
ch of the following problems would be a serious problem for you?
Excessive barking, digging, jumping, not getting along with cats, not getting along with other dogs, not
good with children, not housetrained, too active, not playful with other animals, not playful with
children, not good being left alone, difficult to walk on a leash, too big, too much shedding
How many hours per day will the dog be left alone? _______________________
Where will he/she be kept when alone? ____________________________________________________
Where will the dog sleep at night? __________________________
Will there ever be times the dog is tied? _____________________ If yes, when? ___________________
When you go on vacation/travel, who will care for the dog? ____________________________________
How often and what type of exercise will you give your dog?
Are you interested in a puppy or adult? _________________________________
If puppy, would this be your first puppy? Yes or No
Is this your first dog? Yes or no
What were your previous dogs, if any? _____________________________________________________
Do you have cats? Yes or No How many?__________________
Have you ever had a puppy contract the Parvo virus? Yes or No
If yes, Are you still living where you had the dog with parvo? Yes or No
How long has it been since the dog contracted parvo? ____________________________________
Did the dog survive? Yes or No
Do you currently have any animals? Yes or no
If yes,
What type? _______________________Breed of current dogs: _________________________________
Are your current dogs Fixed? Yes or No
Are they current on vaccines? (DHPP and Rabies) ___________________________________________
What are the ages of your current dogs? __________________________________________________
Name of your veterinarian? _________________________________ City/Town___________________
Have you ever adopted from a shelter/rescue? Yes or No
If so, What rescue organization? _________________________________________________________
Have you ever surrendered an animal to a shelter or rescue? Yes or No
If so, why? ___________________________________________________________________________
How much are you willing to spend on medical bills? ______________ What will you do if the bills
exceed this amount? ___________________________________________________________________
Are you ready to take responsibility for this dog/puppy in all situations for the length of its life? ______
What provisions will you make for the dog should you become unable to care for it?
Have you previously applied with MMHR for the adoption of a dog? Yes or No when? ____________
Have you ever relinquished or returned a dog to MMHR? Yes or no
INTERVIEWER, Please initial that you have discussed the following topics with potential adopter:
heartworm/flea/tick prevention, transition advice, vaccines, ID tag, specific needs and temperaments
of specific dog, return policy, fees, medical records/expenses
I certify that the information above is true and understand that false information provided will result
in nullification of this adoption.
Prospective Adopter Signature: _______________________________________ Date:______________
MMHR Representative Approval: ______________________________________Date:______________
Please sign and save the application. Email the signed PDF and ALL Required
Documents to We will be in contact after
reviewing the adoption application.
Thank You!