Adoption Questionnaire Name*FirstLastAddress*Street AddressCityState / Province / RegionPostal / Zip CodeHome Phone (enter mobile number if same)*United States+1Afghanistan (افغانستان)+93Albania (Shqipëri)+355Algeria (الجزائر)+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua and Barbuda+1Argentina+54Armenia (Հայաստան)+374Aruba+297Ascension Island+247Australia+61Austria (Österreich)+43Azerbaijan (Azərbaycan)+994Bahamas+1Bahrain (البحرين)+973Bangladesh (বাংলাদেশ)+880Barbados+1Belarus (Беларусь)+375Belgium (België)+32Belize+501Benin (Bénin)+229Bermuda+1Bhutan (འབྲུག)+975Bolivia+591Bosnia and Herzegovina (Босна и Херцеговина)+387Botswana+267Brazil (Brasil)+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria (България)+359Burkina Faso+226Burundi (Uburundi)+257Cambodia (កម្ពុជា)+855Cameroon (Cameroun)+237Canada+1Cape Verde (Kabu Verdi)+238Caribbean Netherlands+599Cayman Islands+1Central African Republic (République centrafricaine)+236Chad (Tchad)+235Chile+56China (中国)+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros (جزر القمر)+269Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)+243Congo (Republic) (Congo-Brazzaville)+242Cook Islands+682Costa Rica+506Côte d’Ivoire+225Croatia (Hrvatska)+385Cuba+53Curaçao+599Cyprus (Κύπρος)+357Czech Republic (Česká republika)+420Denmark (Danmark)+45Djibouti+253Dominica+1Dominican Republic (República Dominicana)+1Ecuador+593Egypt (مصر)+20El Salvador+503Equatorial Guinea (Guinea Ecuatorial)+240Eritrea+291Estonia (Eesti)+372Eswatini+268Ethiopia+251Falkland Islands (Islas Malvinas)+500Faroe Islands (Føroyar)+298Fiji+679Finland (Suomi)+358France+33French Guiana (Guyane française)+594French Polynesia (Polynésie française)+689Gabon+241Gambia+220Georgia (საქართველო)+995Germany (Deutschland)+49Ghana (Gaana)+233Gibraltar+350Greece (Ελλάδα)+30Greenland (Kalaallit Nunaat)+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea (Guinée)+224Guinea-Bissau (Guiné Bissau)+245Guyana+592Haiti+509Honduras+504Hong Kong (香港)+852Hungary (Magyarország)+36Iceland (Ísland)+354India (भारत)+91Indonesia+62Iran (ایران)+98Iraq (العراق)+964Ireland+353Isle of Man+44Israel (ישראל)+972Italy (Italia)+39Jamaica+1Japan (日本)+81Jersey+44Jordan (الأردن)+962Kazakhstan (Казахстан)+7Kenya+254Kiribati+686Kosovo+383Kuwait (الكويت)+965Kyrgyzstan (Кыргызстан)+996Laos (ລາວ)+856Latvia (Latvija)+371Lebanon (لبنان)+961Lesotho+266Liberia+231Libya (ليبيا)+218Liechtenstein+423Lithuania (Lietuva)+370Luxembourg+352Macau (澳門)+853Macedonia (FYROM) (Македонија)+389Madagascar (Madagasikara)+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania (موريتانيا)+222Mauritius (Moris)+230Mayotte+262Mexico (México)+52Micronesia+691Moldova (Republica Moldova)+373Monaco+377Mongolia (Монгол)+976Montenegro (Crna Gora)+382Montserrat+1Morocco (المغرب)+212Mozambique (Moçambique)+258Myanmar (Burma) (မြန်မာ)+95Namibia (Namibië)+264Nauru+674Nepal (नेपाल)+977Netherlands (Nederland)+31New Caledonia (Nouvelle-Calédonie)+687New Zealand+64Nicaragua+505Niger (Nijar)+227Nigeria+234Niue+683Norfolk Island+672North Korea (조선 민주주의 인민 공화국)+850Northern Mariana Islands+1Norway (Norge)+47Oman (عُمان)+968Pakistan (پاکستان)+92Palau+680Palestine (فلسطين)+970Panama (Panamá)+507Papua New Guinea+675Paraguay+595Peru (Perú)+51Philippines+63Poland (Polska)+48Portugal+351Puerto Rico+1Qatar (قطر)+974Réunion (La Réunion)+262Romania (România)+40Russia (Россия)+7Rwanda+250Saint Barthélemy+590Saint Helena+290Saint Kitts and Nevis+1Saint Lucia+1Saint Martin (Saint-Martin (partie française))+590Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508Saint Vincent and the Grenadines+1Samoa+685San Marino+378São Tomé and Príncipe (São Tomé e Príncipe)+239Saudi Arabia (المملكة العربية السعودية)+966Senegal (Sénégal)+221Serbia (Србија)+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia (Slovensko)+421Slovenia (Slovenija)+386Solomon Islands+677Somalia (Soomaaliya)+252South Africa+27South Korea (대한민국)+82South Sudan (جنوب السودان)+211Spain (España)+34Sri Lanka (ශ්රී ලංකාව)+94Sudan (السودان)+249Suriname+597Svalbard and Jan Mayen+47Sweden (Sverige)+46Switzerland (Schweiz)+41Syria (سوريا)+963Taiwan (台灣)+886Tajikistan+992Tanzania+255Thailand (ไทย)+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad and Tobago+1Tunisia (تونس)+216Turkey (Türkiye)+90Turkmenistan+993Turks and Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine (Україна)+380United Arab Emirates (الإمارات العربية المتحدة)+971United Kingdom+44United States+1Uruguay+598Uzbekistan (Oʻzbekiston)+998Vanuatu+678Vatican City (Città del Vaticano)+39Venezuela+58Vietnam (Việt Nam)+84Wallis and Futuna (Wallis-et-Futuna)+681Western Sahara (الصحراء الغربية)+212Yemen (اليمن)+967Zambia+260Zimbabwe+263Åland Islands+358Cell / Mobile (enter home number if same)*United States+1Afghanistan (افغانستان)+93Albania (Shqipëri)+355Algeria (الجزائر)+213American Samoa+1Andorra+376Angola+244Anguilla+1Antigua and Barbuda+1Argentina+54Armenia (Հայաստան)+374Aruba+297Ascension Island+247Australia+61Austria (Österreich)+43Azerbaijan (Azərbaycan)+994Bahamas+1Bahrain (البحرين)+973Bangladesh (বাংলাদেশ)+880Barbados+1Belarus (Беларусь)+375Belgium (België)+32Belize+501Benin (Bénin)+229Bermuda+1Bhutan (འབྲུག)+975Bolivia+591Bosnia and Herzegovina (Босна и Херцеговина)+387Botswana+267Brazil (Brasil)+55British Indian Ocean Territory+246British Virgin Islands+1Brunei+673Bulgaria (България)+359Burkina Faso+226Burundi (Uburundi)+257Cambodia (កម្ពុជា)+855Cameroon (Cameroun)+237Canada+1Cape Verde (Kabu Verdi)+238Caribbean Netherlands+599Cayman Islands+1Central African Republic (République centrafricaine)+236Chad (Tchad)+235Chile+56China (中国)+86Christmas Island+61Cocos (Keeling) Islands+61Colombia+57Comoros (جزر القمر)+269Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)+243Congo (Republic) (Congo-Brazzaville)+242Cook Islands+682Costa Rica+506Côte d’Ivoire+225Croatia (Hrvatska)+385Cuba+53Curaçao+599Cyprus (Κύπρος)+357Czech Republic (Česká republika)+420Denmark (Danmark)+45Djibouti+253Dominica+1Dominican Republic (República Dominicana)+1Ecuador+593Egypt (مصر)+20El Salvador+503Equatorial Guinea (Guinea Ecuatorial)+240Eritrea+291Estonia (Eesti)+372Eswatini+268Ethiopia+251Falkland Islands (Islas Malvinas)+500Faroe Islands (Føroyar)+298Fiji+679Finland (Suomi)+358France+33French Guiana (Guyane française)+594French Polynesia (Polynésie française)+689Gabon+241Gambia+220Georgia (საქართველო)+995Germany (Deutschland)+49Ghana (Gaana)+233Gibraltar+350Greece (Ελλάδα)+30Greenland (Kalaallit Nunaat)+299Grenada+1Guadeloupe+590Guam+1Guatemala+502Guernsey+44Guinea (Guinée)+224Guinea-Bissau (Guiné Bissau)+245Guyana+592Haiti+509Honduras+504Hong Kong (香港)+852Hungary (Magyarország)+36Iceland (Ísland)+354India (भारत)+91Indonesia+62Iran (ایران)+98Iraq (العراق)+964Ireland+353Isle of Man+44Israel (ישראל)+972Italy (Italia)+39Jamaica+1Japan (日本)+81Jersey+44Jordan (الأردن)+962Kazakhstan (Казахстан)+7Kenya+254Kiribati+686Kosovo+383Kuwait (الكويت)+965Kyrgyzstan (Кыргызстан)+996Laos (ລາວ)+856Latvia (Latvija)+371Lebanon (لبنان)+961Lesotho+266Liberia+231Libya (ليبيا)+218Liechtenstein+423Lithuania (Lietuva)+370Luxembourg+352Macau (澳門)+853Macedonia (FYROM) (Македонија)+389Madagascar (Madagasikara)+261Malawi+265Malaysia+60Maldives+960Mali+223Malta+356Marshall Islands+692Martinique+596Mauritania (موريتانيا)+222Mauritius (Moris)+230Mayotte+262Mexico (México)+52Micronesia+691Moldova (Republica Moldova)+373Monaco+377Mongolia (Монгол)+976Montenegro (Crna Gora)+382Montserrat+1Morocco (المغرب)+212Mozambique (Moçambique)+258Myanmar (Burma) (မြန်မာ)+95Namibia (Namibië)+264Nauru+674Nepal (नेपाल)+977Netherlands (Nederland)+31New Caledonia (Nouvelle-Calédonie)+687New Zealand+64Nicaragua+505Niger (Nijar)+227Nigeria+234Niue+683Norfolk Island+672North Korea (조선 민주주의 인민 공화국)+850Northern Mariana Islands+1Norway (Norge)+47Oman (عُمان)+968Pakistan (پاکستان)+92Palau+680Palestine (فلسطين)+970Panama (Panamá)+507Papua New Guinea+675Paraguay+595Peru (Perú)+51Philippines+63Poland (Polska)+48Portugal+351Puerto Rico+1Qatar (قطر)+974Réunion (La Réunion)+262Romania (România)+40Russia (Россия)+7Rwanda+250Saint Barthélemy+590Saint Helena+290Saint Kitts and Nevis+1Saint Lucia+1Saint Martin (Saint-Martin (partie française))+590Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)+508Saint Vincent and the Grenadines+1Samoa+685San Marino+378São Tomé and Príncipe (São Tomé e Príncipe)+239Saudi Arabia (المملكة العربية السعودية)+966Senegal (Sénégal)+221Serbia (Србија)+381Seychelles+248Sierra Leone+232Singapore+65Sint Maarten+1Slovakia (Slovensko)+421Slovenia (Slovenija)+386Solomon Islands+677Somalia (Soomaaliya)+252South Africa+27South Korea (대한민국)+82South Sudan (جنوب السودان)+211Spain (España)+34Sri Lanka (ශ්රී ලංකාව)+94Sudan (السودان)+249Suriname+597Svalbard and Jan Mayen+47Sweden (Sverige)+46Switzerland (Schweiz)+41Syria (سوريا)+963Taiwan (台灣)+886Tajikistan+992Tanzania+255Thailand (ไทย)+66Timor-Leste+670Togo+228Tokelau+690Tonga+676Trinidad and Tobago+1Tunisia (تونس)+216Turkey (Türkiye)+90Turkmenistan+993Turks and Caicos Islands+1Tuvalu+688U.S. Virgin Islands+1Uganda+256Ukraine (Україна)+380United Arab Emirates (الإمارات العربية المتحدة)+971United Kingdom+44United States+1Uruguay+598Uzbekistan (Oʻzbekiston)+998Vanuatu+678Vatican City (Città del Vaticano)+39Venezuela+58Vietnam (Việt Nam)+84Wallis and Futuna (Wallis-et-Futuna)+681Western Sahara (الصحراء الغربية)+212Yemen (اليمن)+967Zambia+260Zimbabwe+263Åland Islands+358Email AddressPreferred method of contact*Select valueCellHome PhoneEmailText MessageBest time to reach by phoneHH : MMAMPMAM/PMWould you like to receive text messages for updates? YesNoWhat type of residence do you live in?*ApartmentCondo/TownhouseSingle Family HomePlease confirm that your HOA/POA does not have restrictions on pets over 50 lbs.*I CONFIRMDo you rent or own your home?*RentOwnDoes your landlord or rental agency allow pets?*YesNoThank you for considering Blue Ridge Akitas. Please contact us again when you are eligible to own a pet. Please note: Since you are renting, documentation will have to be provided by the landlord or leasing agency stating that you are permitted to have a pet of 50 lbs. or more. To avoid delays or forfeiture, please verify that you will be able to provide the required documentation prior to receiving your puppy.*Yes, I can provide the required documentationNo, I cannot provide the required documentationYou have indicated that you are permitted to have a pet yet cannot provide documentation stating so. If this is incorrect, please go back and correct the form.If this is correct and you need assistance getting verification, please contact Alicia at Blue Ridge Akitas. You will then be able to complete the adoption questionnaire.Thank you.Do you have a fenced-in area for your puppy?YesNootherHave you owned a dog before?*YesNoWhat Breed(s)Do you currently have other pets?*YesNoWhat other pet(s) do have?Have you ever given up a pet?YesNoPlease explain the reason for giving up your petDoes anyone in the home have pet allergies?*YesNoWill your puppy be around children?*YesNoWhat ages?0-56-1213+Where will your puppy be kept during the day?*Where will your puppy be kept during the evening / overnight?*How would you describe your (family's) activity level?*Couch potatoesMildy activeLike to be outdoorsVery activeWatch UFC to relaxAdd any other comments about your lifestyle, activities, hobbies or special needs you feel are important in choosing your puppy.Why do you want an Akita?I prefer aMaleFemaleIt doesn't matterHow did you hear about Blue Ridge Akitas?Another puppy owner recommendationWeb searchLocal advertisementOtherSend a copy of this message to yourselfWord VerificationSubmitReset Return Home
