Adoption Application Step 1 of 2 - Personal Information 50% * = required fieldsApplicant 1 Name* First Last Applicant 2 Name (Optional) First Last Address* Street Address City Choose OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone:*Cell Phone:Work Phone:Email:* What type of pet are you looking for?* Dog Cat Either This pet is for: Me Family Another Person Please Explain: Please explain why you want a pet, and what you are looking for in a pet: Preferred Dog Size: Small (up to 30 pounds) Medium (40-70 pounds) Large (80-100 pounds) Extra Large (100+ pounds) Any Size Depends on the breed Preferred Dog Activity/Energy Level Low Medium High Any Energy Level Preferred Dog Age: 8wks-3mos 3-6mos 6-18mos 8mos-3yrs 4-6yrs Any Age How many people live in your home?List all people who live in your home (excluding yourself)NameRelationshipAge NameRelationshipAge NameRelationshipAge Click the + icon to the right of the "age" field to add a new row.NameRelationshipAge Click the + icon to the right of the "age" field to add a new row.Do children visit your home on occasion? No Yes If yes, please list all ages: Is anyone in your home allergic to any animals? No Yes Not Sure Please Explain: You live in: House Apartment Duplex Household is: Quiet Active Does your home have a yard? Yes No Is the yard fenced: Yes, it is fenced No, it is not fenced Do you: Own Rent Live w/Parents Live w/Roommates Landlord's Name: First Last Landlord's Phone Number:Parent 1 Name: First Last Parent 1 Phone Number:Parent 2 Name: First Last Parent 2 Phone Number:Are you allowed to have pets? Yes No Do all adult members of your household want to and/or agree to the adoption? Yes No If not, explain: Where will you keep your pet during the day? Inside Outside Where will you keep your pet at night? Inside Outside How many hours in a day will your pet be home alone?Check all that apply. Someone is usually always home 1-4 hours alone 8-12 hours alone I have a doggie door I come home on lunch break I bring my pet to work with me I plan to use doggie daycare The pet I adopt must:Check all that apply. do well with children do well with dogs do well with cats do well with strangers I'm prepared to train my new pet for: Housebreaking Destructive Chewing Separation Anxiety Who will be your new pet(s) primary caretaker: I am willing to spend the following dollar amount for treatment of a pet:* $0-$50 $51-$100 $101-$250 $251-$500 Any amount needed for pet's needs Personal History with Pets Please provide below a list of current and past animals you've owned.Pet NameBreed/TypeWhere did you get this pet?AgeIs this pet still with you?If not, why? Pet NameBreed/TypeWhere did you get this pet?AgeIs this pet still with you?If not, why? Pet NameBreed/TypeWhere did you get this pet?AgeIs this pet still with you?If not, why? Pet NameBreed/TypeWhere did you get this pet?AgeIs this pet still with you?If not, why? Pet NameBreed/TypeWhere did you get this pet?AgeIs this pet still with you?If not, why? Pet NameBreed/TypeWhere did you get this pet?AgeIs this pet still with you?If not, why? Are your current pets up-to-date on all vaccinations, including rabies? Yes No Are your current pets spayed and/or neutered?* Yes No Are your current pets licensed? Yes No Under what circumstances would you give up a pet? Have you ever had to give up a pet?* Yes No Please explain why and what happened:Name of your Veterinarian: First Last Address of your Veterinarian: Street Address City State / Province / Region ZIP / Postal Code
Hearts 4 Paws Mailing Address
