Consultation Request

Please be advised that you must be at least 18 years of age to be considered for adoption of a dog.

Your Name (required)

Your Email (required)

Your Address (required)

Phone (required)

Is anyone in your home allergic to dogs?  Yes No

Has everyone in the home agreed to add a dog to the family?  Yes No

Do you currently have pets? If yes list the pets name, sex, age, and type of pet.

Are all your pets current on vaccines?  Yes No

Are all your pets neutered or spayed?  Yes No

Do you own your own home?  Yes No

If you rent, can you provide a letter from your landlord saying dogs are allowed at the residence?  Yes No

Are you willing to have a New Life representative visit your home?  Yes No

Does your home have a doggie door?  Yes No

Is your yard fenced?  Yes No

Do you have a pool?  Yes No

How many hours per day would your dog be left unattended?

Will your dog be an inside or outside dog or both?  Inside Outside Both

If you move what would you do with the dog?

Are you willing to seek help if you have problems with the dog?  Yes No

How much are you willing to spend on vet bills per year for the dog?

Have you ever had to relinquish a animal? ( take it to the pound, give it to family or friends).  Yes No

What is your plan for the care of the dog if something should happen to you? ( death, divorce, job loss, home loss, ect.)

Are you willing to give the dog time to adjust to your household?  Yes No

How did you learn about us?

I acknowledge that all the information contained in this form is true and correct to the best of my knowledge.  I Agree


Date (date format YYYY-MM-DD)

BISSELL’s Partners for Pets

East Valley New Life Rescue is proud to be a Partner for Pets! BISSELL and have teamed up to help organizations like ours raise money, and now you can help too! When you purchase pet products on and enter the code ADOPT at checkout, a portion of your purchase will be donated to our organization!

It’s simple.
• Shop pet products on
• Enter the code ADOPT at checkout
• Then select our organization!

Learn more at