| I am interested in adopting: |
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| Name: |
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| DOB: |
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| Occupation: |
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| Driver's license number: |
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| Email: |
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| Home phone: |
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| Work phone: |
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| Cell phone: |
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| Address: |
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| City, State, Zip: |
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| Emergency contact: |
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| Did you come to our site intending to adopt a pet today? |
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| Why do you want to adopt this pet? |
Family pet |
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Child's pet |
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Guard dog |
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Hunting dog |
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Companion |
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Companion for another pet |
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Other |
| Have you ever adopted from an animal shelter/humane society/rescue group? |
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| If yes, when? |
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| What happened to this pet? |
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| Are you willing to let us perform a home check? |
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| My home is: |
Apartment |
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House |
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Condo/townhome |
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Trailor/mobile home |
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Urban loft |
| How long have you lived at your current address? |
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| Do you rent? |
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| If so, is your landlord willing to let you have a pet? |
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| Is there a pet deposit? How much? |
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| Has the deposit been paid? |
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| Name and contact for landlord: |
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| How many times have you moved in the past 6 years? |
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| If you move, will your pets go with you? |
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| Would you consider moving somewhere pets are not allowed? |
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| How many people live in your household? |
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| Adults: |
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| Children and ages: |
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| Is anyone in your household allergic to animals? |
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| Does anyone in your household have serious health problems? If so, please briefly explain: |
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| Can you provide a home for this pet for the next 10-15 years? |
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| Do you foresee any major life changes in the next 10-15 years? If so, please briefly explain: |
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| Do you currently have any pets? |
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| If yes, please list type, name, age, breed and sex: |
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| How many pets have you owned in the past 5 years? |
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| Where are these pets now? |
Still with me |
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Put to sleep |
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Died of natural causes |
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Rehomed |
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Sold |
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Ran away |
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Stolen |
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Other |
| Has any dog died on your premise with distemper, parvovirus or other causes within the past 3 months? |
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| Have your pets, past or present, ever lived primarily outdoors? |
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| If yes, please explain: |
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| Where will your pet stay while home alone? |
Basement with pet door |
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Basement |
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Garage |
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Outside |
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Free run of the house |
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One room in the house |
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Crate |
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Other |
| On an average day, how long will your pet be left alone? |
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| Will your pet typically have access to the entire house? |
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| If no, where will the pet be allowed? |
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| Where will your pet sleep at night? |
Garage |
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Basement |
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Outside |
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Free run of house |
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One room in the house |
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My room |
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On the bed |
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Other |
| Will your new pet be allowed on furniture? |
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| Are your current pets spayed/neutered? |
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| If no, please explain: |
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| Are their vaccinations UTD? |
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| Do you know how to protect your dog from heartworms and fleas/ticks? |
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| If you currently have a dog, is it on heartworm preventative? |
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| Do you currently have a veterinarian? |
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| If yes, name and phone: |
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| If yes, can we contact them? |
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| Do you plan to have your pet fully vetted once a year? |
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| What do you expect annual pet care to cost (food, vet, supplies, etc...)? |
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| Who will be responsible for the daily care of this dog? |
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| Do you have a pet door? |
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| Would you consider installing one if necessary? |
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| Is there a yard available? |
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| If yes, is it safely fenced without gaps? |
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| If no, would you consider installing a fence? |
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| If no, how do you plan on containing the dog while outdoors? |
Chain |
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Runner |
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Tie out |
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Leash walk |
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Run/kennel |
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Free run |
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Electronic fence |
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Other |
| Do you currently have a dog house or shelter? |
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| Under what conditions do you think it is okay to leave a dog unattended in an unfenced area? |
Never |
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In a quiet subdivision |
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On a lot of acreage |
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In a rural area |
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When I know they're trained to come back |
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Other |
| Do you current pets, if any, wear ID tags?: |
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| What do you plan to do with your pets when you are out of town? |
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| If you date or marry someone who does not like pets, what would you do? |
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| What prodecures will you use for house training? |
None |
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Crate/confinement |
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Pee pads |
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Rubbing nose in it |
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Punishment |
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Frequent trips outside |
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Positive reinforcement |
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Training classes |
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Other |
| What plans do you have for obedience training? |
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| Have you ever experienced a serious behavioral problem with a pet?: |
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| If yes, please explain.: |
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| If you pet develops a serious medical expensive that becomes too expensive, what would you do? |
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| If your pet develops a frequent urination problem when it is older, what would you do? |
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| Under what conditions would you consider giving up your pet? |
Moving |
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New baby |
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Problems with children |
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Problems with other pets |
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Divorce |
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Behavioral issues |
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Schedule |
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Financial |
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Size became too large |
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Shedding |
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Allergies |
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Medical problem |
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Never |
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Other |
| Have you ever been forced to take an animal t to animal control? |
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| If yes, please explain: |
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| By signing here, I am indicating that this application was filled out truthfully to the best of my knowledge: |
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| Date: |
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