Safe Haven Canine Rescue, Inc.
Midwest City, OK 73110
(405) 821-7367

Canine Adoption Application
You must be at least 21 years old to adopt an Safe Haven Rescued Canine.

All Fields marked with a * are REQUIRED!
Please make the application as complete as possible, blanks only slow down the process

*Last Name :
*First Name:
Co-Applicants Name:
(Spourse,Fiance, Roommate, etc)
*Street Address:
*Home Phone:
Work Phone:
Primary Email:
Secondary Email:

Why did you choose to adopt a canine companion?
Who will be the primary caregiver
(feeding, exercise, training, grooming, etc.) of the pet?
Have you had pets before?
This dog will primarily be a:
Where will the dog be left while you're away from home for the day?
How many hours will the dog be left alone?
(while you are away for the day)
How many adults in the home?
How many children in the home?
Ages of Children in the home:
Does anyone living at your residence have allergies to pets?
If no one in your home has allergies now but develops them in the future, what would you do?
Do all of the adults work?
In what type of dwelling do you live (single family, townhouse, apartment, etc)?
Do you own or rent?:
If you rent, does your lease allow pets?
How long have you lived there?
Are you moving within the next 12 months?
If so, are you planning on taking the dog with you?
Landlord's Name:
Landlord's Phone:
Is your yard fenced?
How tall is the fence?
What material is the fence made of?
Have you ever housetrained an animal before?
If you find it difficult to housetrain,
are you willing to pay a professional trainer to assist you?
Will you relinquish the dog if it is difficult to housetrain?
Are you aware that most dogs cannot be let off leash because they will run off?
Do you realize that a canine may live to be between ten and twenty years old?
Are you aware that it can take 30 days or more for your new dog to adjust to a new environment?
All pets must receive annual vaccinations and an annual physical exam by a veterinarian.
There may also be other miscellaneous medical care costs throughout the year.
How much do you estimate these annual costs to be?
Are you prepared to spend these annual costs on medical care for your dog throughout its lifetime?
Have you ever been convicted of animal neglect, cruelty, or abandonment?

Information about current pets.
Vets Name:
Vets Phone
May we contact your veterinarian for a reference?
Pet's Name
Pet's Name:
Information about previous pets:
Pet # 1
Pet's Name
Age - Health
If Deceased How?
Pet # 2
Pet's Name
Age - Health
If deceased How?

Personal References
Please give at least two references for an in state application.
Give at least three references for an out of state application.

Reference 1
Phone Number

Reference 2
Phone Number

Reference 3
Phone Number

Reference 4
Phone Number

How did you discover Safe Haven Canine Rescue?
(Ex. Friend, Petsmart,Internet Search, other website) ?
(If from other website, please give site name or URL.)
What Color and Size of dog do you prefer?
Do you prefer a male or female?
What age dog do you prefer?
If you are interested in a specific dog, or multiple dog, please indicate their names and any comments.

After pressing "SUBMIT" please print out a copy of the completed application.
The next page is a completed application for your records