Adoption Application for DOGS

2-3-4. Contact Information
	2. APPLICANT
2a. First Name:
2b. Last Name:
2c. Age:
2d. Home Phone:
2e. Cell Phone:
2f. Work Phone:
2g. Primary Email Address:
2h. Secondary Email Address:
Important Note:	Please double check that the email addresses you entered are correct. If they are incorrect, we will be unable to reach you!
2i. Street Address:
2i. City:
2i. State:	- Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
2i. Zip Code:
Mailing Address:	(if different)
2j. Street:
2j. City:
2j. State:	- Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
2j. Zip Code:
	3. CO-APPLICANT
3a. First Name:
3b. Last Name:
3c. Age:
3d. Cell Phone:
3e. Work Phone:
3f. Primary Email Address:
3g. Secondary Email Address:
	Please double check that the email addresses you entered are correct.
4a. Ages of all other adults and children at your home:
4b. Do you live in	an apartment a duplex a townhouse a condo a single house a farm a mobile home Other (please specify below)
4c. May we visit your home prior to application approval?	YesNo
4d. How long have you lived at your current address?
4e. Do you own or rent?	OwnRentLive with parents in their home

5. Renters: Please provide your Landlord's contact information
5a. Landlord's Name:
5b. Landlord's Address:
5b. Landlord's City:
5b. Landlord's State:	- Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
5b. Landlord's Zip Code:
5c. Landlord's Phone:
5d. Do you have your landlord's permission to have a dog?	YesNo
5e. If so, up to what size?	- Select - Up to 25 lbs Up to 50 lbs Up to 75 lbs Up to 100 lbs No Size Restrictions

6. Please describe the kind of dog you are interested in adopting
6a. Please tell us why you want this pet: Check every box that applies	Companion dog for me/my family Companion for my other pet(s) Hunting dog Working dog Guard dog for business Guard dog for residence Show dog Therapy dog Breeding dog Other (please specify below)
6b. Preferred Age:	- Select - Puppy (newborn to 6 months old) Young (7 to 23 months old) Adult (2 to 7 years old) Senior (over 7 years old) Any Age
6c. Preferred Sex:	- Select - Male Female No sex preference
6d. Reason for sex preference
6e. Preferred Breed/Mix:
6f. Have you owned this breed/mix before?	YesNo
6g. Preferred Size:	- Select - Up to 25 lbs Up to 50 lbs Up to 75 lbs Up to 100 lbs No size preference
6h. Preferred Coloring:
6i. Preferred Temperament:
6j. Preferred Activity Level:	HighMediumCalmAny
6k. How long are you willing to commit to this dog's care? Check every box that applies	As long as it is young As long as it is healthy As long as it can work As long as it does hunt As long as I am single Until I/we have children For the dog's whole life Other (please specify below)
6l. Would you consider a Special Needs dog, such as one who requires medication for a permanent but controlled condition?	YesNoUncertain

7. Please list all the pets you have owned IN THE PAST starting with the most recent ones:
#	Pet Name	Species	Sex	Spayed or Neutered	Where did you obtain this pet? What happened to the pet? If deceased, state age & cause of death.
1:		- Select - Bird Cat Chicken Dog Donkey Ferret Fish Gerbil Goat Guinea Pig Hamster Horse Llama Rabbit Rat Sheep Snake Turtle Other	- Select - Male Female	Yes No
2:		- Select - Bird Cat Chicken Dog Donkey Ferret Fish Gerbil Goat Guinea Pig Hamster Horse Llama Rabbit Rat Sheep Snake Turtle Other	- Select - Male Female	Yes No
3:		- Select - Bird Cat Chicken Dog Donkey Ferret Fish Gerbil Goat Guinea Pig Hamster Horse Llama Rabbit Rat Sheep Snake Turtle Other	- Select - Male Female	Yes No
4:		- Select - Bird Cat Chicken Dog Donkey Ferret Fish Gerbil Goat Guinea Pig Hamster Horse Llama Rabbit Rat Sheep Snake Turtle Other	- Select - Male Female	Yes No

8. Please list all the pets you CURRENTLY own:
Pet #	Pet Name	Species	Sex	Spayed or Neutered	Where did you obtain this pet? State age.
1:		- Select - Bird Cat Chicken Dog Donkey Ferret Fish Gerbil Goat Guinea Pig Hamster Horse Llama Rabbit Rat Sheep Snake Turtle Other	- Select - Male Female	Yes No
2:		- Select - Bird Cat Chicken Dog Donkey Ferret Fish Gerbil Goat Guinea Pig Hamster Horse Llama Rabbit Rat Sheep Snake Turtle Other	- Select - Male Female	Yes No
3:		- Select - Bird Cat Chicken Dog Donkey Ferret Fish Gerbil Goat Guinea Pig Hamster Horse Llama Rabbit Rat Sheep Snake Turtle Other	- Select - Male Female	Yes No
4:		- Select - Bird Cat Chicken Dog Donkey Ferret Fish Gerbil Goat Guinea Pig Hamster Horse Llama Rabbit Rat Sheep Snake Turtle Other	- Select - Male Female	Yes No

8a. Are/were all your dogs given monthly heartworm prevention?	YesNoN/A
8b. If so, please indicate the brand(s) of heartworm prevention
8c. Where do/did you purchase it? Check every box that applies	From a veterinarian's office On line From a feed store From Wal Mart From another convenience store From a pet store Other (please specify below)
8d. Do any of your current dogs have physical problems? Explain
8e. Do any of your current dogs have behavioral problems? Explain
8f. Do any of your current dogs have dominance problems? Explain

9. Veterinarian Information
	Current or Primary Veterinarian	Former or Secondary Veterinarian
9. Name:
9. Street Address:
9. City:
9. State:	- Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming	- Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
9. Zip Code:
9. Phone:
PLEASE CALL YOUR VET(S) AND GIVE CONSENT TO RELEASE MEDICAL INFORMATION POSTED ON YOUR FILE.

10. Your new dog's living conditions
10a. Where will your new dog spend its days? Check every box that applies	Indoors Crated In basement In garage On Porch Locked in room Loose in fenced yard Loose unfenced Tied outside In a dog house In a kennel run Other (please specify below)
10b. Where will your new dog spend its nights? Check every box that applies	Indoors In bedroom Crated In basement In garage On porch Locked in room Loose in fenced yard Loose unfenced Tied outside In a dog house In a kennel run Other (please specify below)
10c. Will the dog be allowed in the house?	Yes No
10d. How long each day will the dog be left alone (without humans)?	- Select - Less than 2 hours per day Between 2 and 4 hours per day Between 4 and 6 hours per day Between 6 and 8 hours per day Between 8 and 10 hours per day Between 10 and 12 hours per day More than 12 hours per day
10e. Where will the dog stay when it is left alone?
10f. Are you familiar with the use of a dog crate to train the pet during your absence or at night?	Yes No
10g. Is your yard fenced?	Yes No
10h. If so, please describe the type of fence, its height and the dimensions of the fenced area
10i. If you do not have a fence, will you install one?	Yes No Uncertain
10j. What is the approximate size of the dog's yard area (dimensions)?
10k. How will you exercise your new dog? Check every box that applies	Leash walks every day Will have cable or dog run in the yard Will be free to run in fenced yard Will have supervised access to unfenced yard Will be free to roam around (Off leash and unsupervised in unfenced area) Will bring to dog park (Public area where dogs can run and play together off-leash) Other (please specify below)
10l. Will you take the dog to an obedience training class?	Yes No Uncertain
10m. Do you plan to keep your new dog on heartworm prevention?	Yes No Don't know
10n. How much do you expect to spend on regular health maintenance for your dog in a year? NOT including food
10o. What behavior or circumstances would cause you to give up your pet? Check every box that applies	Aggression Biting Shedding Destructive Housetraining problems New baby Pregnancy Divorce Marriage Medical problems Financial problems Losing interest Allergies Pet not adjusting No time Moving Training problems Other (please specify below)
10p. Have you ever sold, given away, or surrendered a pet to a shelter?	Yes No
10q. If yes, please specify why:
10r. Please tell us why you want a dog:
10s. Please tell us a little of your lifestyle, your family including any special activities in which your dog would be included. (If you have any special requirements or requests for a dog, please let us know so that we can more carefully match a dog to your lifestyle):
10t. If and when you move, what will you do with your dog?
10u. What will you do with the dog if you can no longer keep him/her?
10v. What plans will you make for the dog during your vacation?
10w. Who will be the dog's primary caretaker?
10x. Who will take care of the dog if something happens to his/her caretaker?
10y. In case you have to evacuate because of a natural disaster, where will your pet(s) stay?
10z. What would you do if the pet becomes very ill?
10z1. How far with treatment will you go?
10z2. Have you, or any member of your family/household, been cited for leash law violations or cruelty to animals in the past?	Yes No
10z3. If yes, please specify:
10z4. Is there anything else you would like us to know about your application?
10z5. How did you hear about us?

11 I/We assert that the information I(we) provided is complete, true and accurate to the best of my/our knowledge. I/We understand that completion and submission of this application does not guarantee adoption of a dog. I/We hereby give permission to contact my/our Veterinarian(s) and Landlord, if applicable. Check this box to confirm

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