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?*DogCatEitherThis pet is for:MeFamilyAnother PersonPlease 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 LevelLowMediumHighAny Energy LevelPreferred Dog Age:8wks-3mos3-6mos6-18mos8mos-3yrs4-6yrsAny AgeHow many people live in your home?List all people who live in your home (excluding yourself)NameRelationshipAge NameRelationshipAge NameRelationshipAge NameRelationshipAge Click the + icon to the right of the "age" field to add a new row.Do children visit your home on occasion?NoYesIf yes, please list all ages:Is anyone in your home allergic to any animals?NoYesNot SurePlease Explain:You live in:HouseApartmentDuplexHousehold is:QuietActiveDoes your home have a yard?YesNoIs the yard fenced:Yes, it is fencedNo, it is not fencedDo you:OwnRentLive w/ParentsLive w/RoommatesLandlord'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?YesNoDo all adult members of your household want to and/or agree to the adoption?YesNoIf not, explain:Where will you keep your pet during the day?InsideOutsideWhere will you keep your pet at night?InsideOutsideHow 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-$500Any amount needed for pet's needsPersonal 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?YesNoAre your current pets spayed and/or neutered?*YesNoAre your current pets licensed?YesNoUnder what circumstances would you give up a pet?Have you ever had to give up a pet?*YesNoPlease 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
