Carolina Bully Breed Rescue

Adopter's Information:





Zip Code:

Phone Number:


References: (1)

(name and   (2)

 number)     (3)

Place of employment:

Work number:

Have you had any prior experience with bully breeds, if so what?

Do you have any other pets, if so what breeds, ages, spayed/neutered?

Do you have any children, if so what ages?

Do you plan to keep the dog inside or out?

Do you have a fenced in yard?

Have you ever been convicted of cruelty to animals?

If the animal has not already been spayed/neutered do you plan to have it spayed/neutered? When?


Information About Adopted Animal:

Pets Name:




Color and description:


I agree that the animal is being adopted for myself and will not be sold, adopted, or given to another party without first notifying original rescue.  _________ (initial)

I agree to care for the animal in a humane manner and be a responsible animal guardian. This includes supplying adequate food, water, shelter, attention, and medical care.  _________ (initial)

I agree that if at any point I can not keep the animal, I will return him/her to the original rescue without requesting a fee or find an adequate home for the animal with approval from the original rescue.  _________ (initial)

I understand and agree that the current rescue makes no guarantees about the animal's temperament and is not responsible for future damages or injuries caused by the animal.  _________ (initial)

I give the current rescue permission to call my home at any reasonable time to assure that the animal is being properly treated and cared for.  _________ (initial)

I agree to keep the rescue informed of my current home address and phone number.  _________ (initial)

I agree if the animal has not spayed/neutered I will take it to the appt. scheduled by myself or the rescue group and will fax or mail the records to the rescue within 15 days after the animal has been spayed/neutered. _________ (initial)

I agree to donate the amount of $______ to help cover the cost of the animals expenses. _________ (initial)

I agree that all statements I have made on this form are true. If it is found that any statements I have made on this form are not true the adopted animal can be confiscated.

Adopter's Signature:


Current Guardian's Signature: