Adoption Application
  1. Which 11th Hour Dog do you wish to adopt?(*)
    Which 11th Hour Dog do you wish to adopt?
  2. Your Name(*)
    Please let us know your name.
  3. Your Email(*)
    Please let us know your email address.
  4. Street(*)
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  5. Apt
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  6. City(*)
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  7. State(*)
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  8. Zip Code(*)
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  9. Phone
    Please include your phone number
  10. Cell
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  11. Employer(*)
    Please enter the name of your employer
  12. Employer's Phone(*)
    Please enter your employer's phone number


  13. Household information

  14. List name & contact information for someone you live with (if applicable)
  15. Name
    Please enter the name of someone you live with (if applicable).
  16. Phone
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  17. Email
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  18. Have all adult members of your household agreed to the adoption?
  19. (*)
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  20. Please list the name and age of all members of your household
  21. Invalid Input


  22. Information about your current pets

  23. Type / Breed of Pet #1
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  24. Pet Name
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  25. How long has this pet lived with you?
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  26. Are the vaccinations up to date?
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  27. Has this pet been sprayed / neutered?
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  28. Please enter any additional relevant information
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  29. Type / Breed of Pet #2
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  30. Pet Name
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  31. How long has this pet lived with you?
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  32. Are the vaccinations up to date?
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  33. Has this pet been sprayed / neutered?
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  34. Please enter any additional relevant information
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  35. Type / Breed of Pet #3
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  36. Pet Name
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  37. How long has this pet lived with you?
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  38. Are the vaccinations up to date?
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  39. Has this pet been sprayed / neutered?
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  40. Please enter any additional relevant information
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  41. Information about your past pets

  42. Type / Breed of Past Pet #1
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  43. Pet Name
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  44. How long did this pet live with you?
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  45. Were the vaccinations up to date?
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  46. Was this pet sprayed / neutered?
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  47. Is this pet deceased?
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  48. Please enter any additional relevant information
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  49. Type / Breed of Past Pet #2
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  50. Pet Name
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  51. How long did this pet live with you?
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  52. Were the vaccinations up to date?
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  53. Was this pet sprayed / neutered?
    Invalid Input
  54. Is this pet deceased?
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  55. Please enter any additional relevant information
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  56. Veterinarian Information

    Please contact your vet and advise them that 11th Hour Rescue NY will be calling for a "Vet Check" and give your permission to speak to us.

  57. Veterinarian Name
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  58. Address
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  59. Phone (please include area code)
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  60. Personal References

    Provide two references, only one of which may be a family member.

  61. Name(*)
    Please enter the name of your first reference.
  62. Address(*)
    Please enter the address of your first reference
  63. Phone (please include area code)(*)
    Please enter the phone number of your first reference
  64. Relationship(*)
    Please enter your relationship with this reference

  65. Second Reference
  66. Name(*)
    Please enter the name of your second reference
  67. Address(*)
    Please enter the address of your second reference
  68. Phone (please include area code)(*)
    Please enter the phone number of your second reference
  69. Relationship
    Please enter the relationship with this reference


  70. Household Questionnaire

  71. Is anyone in your household allergic to dogs/
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  72. Please explain
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  73. If you have children, please describe any experiences they've had with dogs
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  74. Please choose which option best fits your lifestyle
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  75. Do you own or rent your residence?
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  76. If renting, please provide your landlord's name and contact information
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  77. What type of home do you live in?
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  78. If other, please explain
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  79. Do you have a fenced in yard?
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  80. If yes, please describe the type and height of fence.
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  81. Adoption Questionnaire

  82. What are your reasons for adopting a dog? Select all that apply








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  83. If other, please explain
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  84. Why do you wish to adopt this particular dog?
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  85. Who will be the primary caretaker?(*)
    Who will be the primary caretaker?
  86. The average yearly cost for a healthy dog is between $500 to $700. Are you prepared to bear this cost?(*)
    Please let us know if you are willing / able to bear the yearly costs for maintaining a healthy dog

  87. On average, how long will the dog be left alone each day?(*)
    On average, how long will the dog be left alone each day?

  88. What arrangements do you expect to make to care for this dog if you are away from home for an extended period of time>(*)
    What arrangements do you expect to make to care for this dog if you are away from home for an extended period of time>

  89. Where will the dog be kept when you're at work or otherwise not at home for brief periods?(*)
    Where will the dog be kept when you're at work or otherwise not at home for brief periods?

  90. How do you plan to exercise this dog?(*)
    How do you plan to exercise this dog?

  91. Where will the dog sleep at night?(*)
    Where will the dog sleep at night?

  92. Select the kinds of personal situations where you might consider surrendering your dog?(*)












    Select the kinds of personal situations where you might consider surrendering your dog?

  93. Are you willing to take the time to housebreak this dog?(*)
    Are you willing to take the time to housebreak this dog?

  94. Do you understand that changing a dog's environment / schedule may cause the dog to have accidents?(*)
    Do you understand that changing a dog's environment / schedule may cause the dog to have accidents?

  95. How do you plan on training this dog?(*)
    How do you plan on training this dog?

  96. Are there any habits you will not tolerate from this dog?(*)
    Are there any habits you will not tolerate from this dog?