* Adopter's Name * Age * Address * City * State * Zip * E-mail Address * Home Phone * Employer * Work Phone * Are you expecting a child or planning a family? Yes No How many children are currently living at home? Names and ages of all children included above: * Besides those people listed above, are there others residing in your home? Yes No Names, ages, relationship of other residents * Is everyone in the household in agreement about adopting a pet? Yes No Haven't discussed Surprise for household member * Is anyone in your home allergic to animals? Yes No If yes, to what specific kinds of animals? * Does anyone in your home have asthma? Yes No * Do you own or rent your home? Own Rent If you rent, please provide name and phone number of your landlord: If renting, please indicate any restrictions on pets (size, breed, declawed cats, etc) * Please describe your current dwelling: * How long have you lived at your current address? * If less than two years, please provide your previous address: * In what type of neighborhood is your home located? City Suburban Rural Other * Does your city, township or county have a dog ordinance banning the ownership of specific breeds of dogs? Yes No * Does your home have a yard? Yes No * Is there a securely fenced in area for a dog? Yes No If not, explain how and where you will allow the dog to exercise and relieve itself: If your yard is fenced, please describe what kind: * Do you have other pets at this time? Yes No >If yes, are they spayed or neutered? Yes No If not, why are they not spayed or neutered? If other dogs, are they currently on heartworm prevention? Yes No If yes, what type? Iverheart Interceptor Sentinal Revolution Tri-Heart Heartgard Other Where do you get your heartworm prevention from? Vet Online Pharmacy Other If not on heartworm prevention, please explain Are the other pets current on their vaccinations? Yes No If not, please explain Are the other pets indoors or outdoors? Indoors Outdoors Please describe the other pets in your home (type, gender, etc): * Have you owned dogs or cats previously? Yes No If yes, please list their names, breed and why you no longer have them: * Where will your new pet live? Indoors Outdoors Both * Which pet are you interested in adopting? * What attracted you to this pet that you are applying to adopt? * Do you have any experience with this breed? (If yes, please explain) * What role would you like your new pet to play in your life? * Please describe where the dog will stay when you are home: * Please describe where the dog will stay when you are away during the day: * Please describe where the dog will sleep at night: * Do you plan to use a crate for the dog? Yes No * Why or why not? * Do you currently have a crate for the dog? Yes No * Who will be the primary caretaker of this pet? * Have you adopted a pet before? No Rescue Animal Shelter Humane Society If you have adopted before, please tell us from where (name, phone number) * Please provide us with the name, address, and phone number of your current veterinarian (NOTE: some vets require that you call and authorize them to talk to us). If you have used any other veterinarian(s), please list names and phone numbers. Indicate which pets they treated. * Please provide the names and phone numbers of THREE personal references NOT related to you: * The information provided in this application (in its entirety) is true to the best of my knowledge as of the date on this application. I agree that either my signature on this copy or submission of this form by email will constitute a legally signed document (enter your name here to "sign" on the internet) or sign below if done on hard copy). powered by FormGenics.com 