Adopter Information Questionaire
Jackson’s Legacy Bully Breed Rescue - PO Box 1077,  Broadalbin, NY 12025
In order to better match your interest in a rescued Bully, we ask that you fill out the
following questionnaire, which we will maintain.

Date  ________________
How did you learn of Jackson’s Legacy Bully Breed Rescue? ____________________________________
Potential Adopter(s) Name(s):
1. _____________________________________________
            Home #______________________________   Work #______________________________
2. ______________________________________________
     Work #_______________________________
Street address __________________________________________________________________
City/State/ZIP __________________________________________________________________
E-mail__________________________________________________

Please tell us about your home:
Do you live in (circle) - House - Townhouse - Apartment - Duplex - Other__________________
Own or rent? _________   If own how long: ____________________
IF renting - Landlord name & # : ___________________________________________
Type of setting (city, suburb, country, etc.)___________________________________________
# of adults ________    # of children _________ Ages______________________________
Do children frequently visit?______________________________________________________
Do you have a fenced yard ___________ Type/height of fence ___________________________
Do you have a chain link dog kennel:____________
Do you have a trolley, chain or other device used to tie a dog outdoors:_____________________
Is someone home during the day? _________ # Hours the dog will be alone_________________
Where will the dog be during the day? ___________________ At night? ___________________

Please tell us a little about you:
Applicant's Employer ______________________________      Position ______________________
Co-applicant Employer _____________________________     Position ____________________
Other animals in the home:
Name:                     Breed:              Age:     Sex:     S/N?             Characteristics(friendly/dominant/shy):
_______________ ___________ ____  ______ _____  _____________________________________
_______________ ___________ ____  ______ _____  _____________________________________
_______________ ___________ ____  ______ _____  _____________________________________
_______________ ___________ ____  ______ _____  _____________________________________
_______________ ___________ ____  ______ _____  _____________________________________

Other pets you have had in the last 10 years:
Type/Name                       Age      Sex     Altered?   Where are they now?  If deceased, give reason.
_________________     ____     ____     ______     _______________________________________
_________________     ____     ____     ______     _______________________________________
_________________     ____     ____     ______     _______________________________________
_________________     ____     ____     ______     _______________________________________

Do all members of the home know you are interested in adopting a dog?_______________
Have you ever been convicted of violating animal control laws?__________
Have you ever been convicted of animal cruelty?________________
Have you ever owned a Pit Bull/Bully breed before?____________________
Are you familiar with the characteristics and temperament of a Bully?____________
Why do you want a BULLY? ______________________________________________________
______________________________________________________________________________
How will the dog be exercised _____________________________________________________
______________________________________________________________________________
Do you plan to do obedience training with your rescued dog?_____________________
Who will be the primary caretaker for this dog? ____________________________________

PET PREFERENCES (if any):
M or F ________ Age ____--_______ Would you consider over 5? __________ Over 8?________
Specific likes or dislikes Color ____________ Coat ____________ Other___________________
Size (circle any you would accept) - Toy - Small - Medium – Large - Giant
Will you crate the dog? _________    Do you own a crate? ______
Other breeds that you might like:
______________________________________________________________________________
Do you realize that the dog will most likely be a mix breed?   ____________________________
Check the traits most important to you:
___ Good with children    ___ Will run with jogger        ___ Travels well
___ High energy level        ___ Can eventually go off leash     ___ Friendly
___ Low energy level        ___ Won't need obedience training     ___ Doesn't chew
___ Doesn't jump up        ___ Good with cats            ___ Plays fetch
___ Good with other dogs    ___ Obedience competition potential
Other traits/characteristics that are important to you:
______________________________________________________________________________
Would you consider fostering a dog that does not match your preferences while waiting to adopt?________________________________________________________________________


REFERENCES:
Please give the names and phone numbers, and your relationship of two references who are NOT FAMILY: __________________________________________________________________________

__________________________________________________________________________
Please give the name, address and phone number of a close FAMILY contact:

_______________________________________________________________________________
Please give the name, address and phone number of the veterinarian you plan to use (If you have used this vet
 in the past please notify their staff and give permission for us speak to them regarding your pets medical history.):

______________________________________________________________________________
List other rescues/shelters to whom you have applied: _____________________________________________________________________

I REALIZE THAT ADOPTING A DOG REQUIRES A 10-15 YEAR COMMITMENT, THAT THE MEDICAL HISTORY OF THIS PET IS PROBABLY UNKNOWN, THAT THIS DOG WILL PROBABLY NEED FURTHER TRAINING AND OBEDIENCE CLASSES AND I AM WILLING TO BEAR THIS COST AND RESPONSIBILTY. I ACKNOWLEDGE THAT ALL THE INFORMATION CONTAINED IN MY APPLICATION FORM IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY MISREPRESENTATIONS OF FACTS MAY RESULT IN THE REMOVAL OF THE ADOPTED DOG FROM MY HOME BY JACKSON'S LEGACY BULLY BREED RESCUE. I ALSO REALIZE THAT I MAY EXPERIENCE BREED DISCRIMINATION AND THAT I AGREE TO RETURN THE ANIMAL TO JACKSON’S LEGACY RESCUE IF I NEED TO REHOME THE DOG FOR ANY REASON.

By signing this form, I give Jackson’s Legacy Bull Breed Rescue permission to request information from the
sheriff’s dept regarding any animal cruelty or abuse investigations.

Signed ____________________________________________Date _______________________

DL # ____________________________________   State _________    Exp. Date ________________________
(If this application is sent back to me electronically, your typed name is considered your legal signature)

Signed ____________________________________________ Date _______________________
(If this application is sent back to me electronically, your typed name is considered your legal signature)

Mail to: Lori Smith
Jackson’s Legacy Bully Breed Rescue
PO Box 1077
Broadalbin, NY 12025
or e-mail to:  info@jacksonslegacy.org