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Personal Information
First Name
Last Name
Age
E-Mail
Select one
Under 18
18-20
21-23
23-25
25-35
35-45
Over 45
Address
City
State
Zip
Occupation
Work Phone
Cell Phone
Home Phone
Briefly tell us about the other adults in your household
Name
Relationship to you
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Spouse
Domestic Partner
Roommate
Relative
Other
Renter
Age
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18-20
21-23
23-25
25-35
35-45
Over 45
Name
Relationship to you
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Spouse
Domestic Partner
Roommate
Relative
Other
Renter
Age
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18-20
21-23
23-25
25-35
35-45
Over 45
Name
Relationship to you
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Spouse
Domestic Partner
Roommate
Relative
Other
Renter
Age
Select one
18-20
21-23
23-25
25-35
35-45
Over 45
Briefly tell us about any children in your household
Name
Relationship to you
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Son/Daughter
Niece/Nephew
Other Relation
Not Related
Age
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1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Name
Relationship to you
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Son/Daughter
Niece/Nephew
Other Relation
Not Related
Age
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1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Name
Relationship to you
Select one
Son/Daughter
Niece/Nephew
Other Relation
Not Related
Age
Select one
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Residential Information
If your application is approved will you consent to a home check.
Yes
No
Do you live in a
house
apartment
other
Do you
own
rent
live with family
live with friends
Does your residence have:
a fenced yard
a doggie door
a patio
a porch
yes
no
yes
no
yes
no
yes
no
If you're renting your residence please answer the following:
Landlord's name
Phone number
Does your landlord:
Allow pets
Yes
No
Don't know
Have size restrictions
Yes
No
Don't know
Charge a deposit
Yes
No
Don't know
Charge extra rent
Yes
No
Don't know
Your new pet
Which animal are you interested in adopting ?
Why are you planning to adopt a dog? (check all that apply)
For a companion
For hunting
Bark at strangers
For yourself
For your family
Buddy for another pet
As a gift
As a guard dog
Running partner
What qualities are you looking for in a new dog?
Please list any concerns you have about your new pet,
or any questions you may have for us.
Do you have experience training dogs for any of the following:
Obedience
Housebreaking
Agility
Other
yes
no
yes
no
yes
no
How will you deal with destructive behavior like chewing, digging, or jumping?
What will you do if your new dog bites or snaps at a family member?
Who will have the primary responsibility for the following:
Feeding
Obedience
Vet Care
Exercise
Routine health care can cost up to $300.00 a year and emergencies are often over $1,000. Are you willing to provide this care if necessary ?
Yes
No
Where will your new pet be kept:
At night
If you move
During the day
When on vacation
On an average day how long will the pet be left alone?
How many days a week?
What will you do with your new dog if you can no longer keep it?
Will your new pet be allowed
On the bed
Yes
No
In the car
Yes
No
In the pool
Yes
No
In the yard
Yes
No
In the house
Yes
No
On the couch
Yes
No
Current or Previous Pets
How many pets do you have now?
Dogs
Cats
Others
Are your current pets vaccines up-to-date?
Yes
No
Don't Know
Are they all spayed and neutered?
Yes
No
Don't know
Current veterinarian's name:
Phone #
May we contact them to ask about your current pets?
Yes
No
Have you ever had to relinquish an animal to a shelter?
Yes
No
If so, what were the circumstances?
How many pets have you had in the last 10 years?
Dogs
Cats
Others
Where are they now?
Please tell us a little bit about your previous pets and anything
else you would like us to know about your current pets.
Thank you for taking the time to complete our application.
We will review it shortly and contact you very soon.
Click the submit button to send us the form, and return to our home page.
