Rlogo.jpg (12507 bytes)


Autumn Valley Golden Retriever Rescue Inc

P.O. Box 779 Vestal NY 13850

Application for Adoption (please print and mail)

Name:  _____________________________________________Date:____________

Address:  ____________________________________________________________

                 ___________________________________________________________

Phone Number:  ________________________  E-Mail ______________________

Do you own or rent your home?  _______________________________________ 

Attention renters

A copy of your lease or a statement from your landlord, that a large dog is permitted, must

be attached to your application or else it cannot be processed.

Is yard area fenced in?  ______________  If yes, what type of fence do you have? _________________

How will you exercise your Golden?:  ______________________________________________________

Are there other animals in the home?  __________________________________________________________

What type of animals?  _____________________________________________________________________

Children?  Ages?  _______________________

                            _______________________

                           _______________________

Which veterinarian have you used or will you be using? (Please include a phone number if we can

use him/her as a  reference): __________________________________________________________________________

Please give two references with phone numbers:

___________________________________________________________________

___________________________________________________________________

How did you hear about our organization?

____________________________________________________________________________________

____________________________________________________________________________________

Please take a moment to tell us more about you, your family and any previous pets that you may

have owned.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Why do you want a golden retriever?

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Are there any specific qualities that you are looking for in a golden retriever?

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

I certify that my answers to the questions and statements are true and correct. 

 

________________________________________________                      ________________________

                        Signature                                                                                  Date

Our program requires all of our dogs to be seen by a veterinarian to perform the following

medical procedures: spay/neutering, rabies vaccination, DHLPP, worming, heartworm testing and micro chipping

 The $250.00 adoption fee does not constitute the sale of the dog.

Please return this form to :              Autumn Valley Golden Retriever Rescue

                                                                        P.O. Box 779

                                                                        Vestal, NY 13850