DOG ADOPTION APPLICATION
Date
Time
I am interested in adopting the following dog:
Contact Info
First Name
MI
Last Name
Maiden Name
Street Address
City
State
Zip
Cell Phone
Home Phone
Email
Date of Birth (MM/DD/YYYY)
Driver's License #
Co-Applicant Information
First Name
MI
Last Name
Maiden Name
Date of Birth (MM/DD/YYYY)
Driver's License #
Cell Phone
Home Phone
Email
Relationship with APPLICANT
Household Information
Housing Status
Own
Rent
Length of time at current residence (years, months)
If you are renting, please list the name and phone number of your landlord
Number of children in household:
Ages
Number of Adults in household:
Please list full legal names & birthdays (MM/DD/YYYY) of all adults in household:
PLEASE list full legal names including middle initial, & birthdates (MM/DD/YY) of additional adults in your household beyond names applicants.
If you have been at your current address for less than 2 years, please list your previous address
Street Address
City
State
Zip
Length of time at this residence (years, months)
Employment
Applicant Employer
Hours worked per week
Shift
Work from Home?
Yes
No
Employed here for how many years, months
Previous Employer (if less than one year)
Hours worked per week
Co-Applicant Employer
Hours worked per week
Shift
Work from Home?
Yes
No
Employed here for how many years, months
Previous Employer (if less than one year)
Hours worked per week
Please answer the following questions:
Will this be your first dog?
Yes
No
How many hours a day will the dog or puppy be left alone?
Who will be responsible for feeding, training and vet care?
Does anyone go home for lunch?
Yes
No
Do you have an outside run?
Yes
No
Do you have a fenced yard?
Yes
No
Height of fence
Do you have a dog house?
Yes
No
Do you have a training crate?
Yes
No
Do you have a tie out for the dog?
Yes
No
Do you or anyone in your household have an allergy to pets?
Yes
No
Have you attended dog training classes?
Yes
No
Are you willing to go if mandated?
Yes
No
Have you ever had to get rid of a pet?
Yes
No
If yes, please explain
Where will the dog be kept during the day?
Crate
Basement
Loose in house
Loose in yard
Penned outdoors
Tied outdoors
Other
If Other, please explain
Where will the dog be kept at night?
Crate
Basement
Loose in house
Loose in yard
Penned outdoors
Tied outdoors
Other
If Other, please explain
Where will the dog be kept when you are gone?
Crate
Basement
Loose in house
Loose in yard
Penned outdoors
Tied outdoors
Other
If Other, please explain
Where will the dog be kept in bad weather?
Crate
Basement
Loose in house
Loose in yard
Penned outdoors
Tied outdoors
Other
If Other, please explain
Vet History
**Please contact your vet clinics and release your pet's records to us **
Current Pets: List all pet (canines and felines only) that you currently have. Indicate “NONE” if you currently have no pets. Do not include your parents' pets.
None
Dog
Cat
Name
Breed
Temperament
Age
Length of ownership
Mainly kept
Inside
Outside
Vet Clinic Used
Clinic City & Phone Number
Dog
Cat
Name
Breed
Temperament
Age
Length of ownership
Mainly kept
Inside
Outside
Vet Clinic Used
Clinic City & Phone Number
Dog
Cat
Name
Breed
Temperament
Age
Length of ownership
Mainly kept
Inside
Outside
Vet Clinic Used
Clinic City & Phone Number
Dog
Cat
Name
Breed
Temperament
Age
Length of ownership
Mainly kept
Inside
Outside
Vet Clinic Used
Clinic City & Phone Number
Please list any other current pets
Past Pets: List all pets (canine and felines only) owned in the last 10 years. Indicate “NONE” if you’ve not had pets in the last 10 years. Do not include your parents’ pets.
None
Dog
Cat
Name
Breed
Temperament
Age
Length of ownership
Mainly kept
Inside
Outside
Vet Clinic Used
Clinic City & Phone Number
Date of Death
Dog
Cat
Name
Breed
Temperament
Age
Length of ownership
Mainly kept
Inside
Outside
Vet Clinic Used
Clinic City & Phone Number
Date of Death
Dog
Cat
Name
Breed
Temperament
Age
Length of ownership
Mainly kept
Inside
Outside
Vet Clinic Used
Clinic City & Phone Number
Date of Death
Dog
Cat
Name
Breed
Temperament
Age
Length of ownership
Mainly kept
Inside
Outside
Vet Clinic Used
Clinic City & Phone Number
Date of Death
Please list any other past pets
Please read and type in your name
I certify that all information I have given on this application is true. I understand that any false information, unanswered questions or omitted information may result in rejection.
I hereby give my authorization to release of the veterinarian / clinic records for all my pets (past and present), including but not limited to: examinations, vaccine history, tests, surgeries, clinics notes, etc. to H.O.P.E. Safehouse, Inc.
Applicant Signature (digital)
Date
Co-applicant Signature (digital)
Date