Date:
Pup Interested In:
1st choice:
2nd choice:
1.Name of applicant and your age:
a.Name of applicant’s spouse/partner and their age:
2.COMPLETE Address:
3.How long have you lived at this address?
4.Tele: (home) (work) (cell)
5.Email address:
6.With whom are you employed and how long employed here?
a.Spouse/partner’s employer and how long employed here?
7.Occupation:
a.Spouse/partner’s occupation:
8.Number of children living in this household:
a.List their 1st name(s) only & their age(s):
9.Number of adults living in this household:
a.Their names, ages, (& occupations of those not listed above):
10.Is anyone living in this household either pregnant or trying to become pregnant?
11.What type of environment do you live in? Rural Suburb City
Housing: Apt. House Duplex Mobile Home Other:
12.Do you rent or own?
a.If you rent, are you permitted to own a companion animal under 25lbs? Yesb.If you rent, are you permitted to own a companion animal Over 25lbs? Yesc.Name and telephone# of property owner/management:
13.What other dogs/cats have you previously owned and what happened to them (state pet’s name, age, if speutered, reason forgiving up/cause of death?
14.What other dogs/cats currently live in your home:(please list: names, breed, sex, age, any health issues they may have & if speutered):
15.Are there any other types of animals currently living in your home? If so, describe:
16. What do you know about the breed in question (it is required that you research this breed’s traits/ habits)?
17. Are there any specific habits/problems you are not willing to work with? Please specifiy.
18. Sexual preference: M F No preference
19. Do you have a fenced-in yard & is it connected to the house (entire yard fenced, front yard only, backyard fenced & attached to
back door, etc.)?
20. What is the height & dimensions of the fenced-in area? Please, be specific, as this info is REQUIRED & PERTINENT to the
approval of your application?
21. Please, describe your fencing materials (chain-link, wooden stockade, vinyl rail…2, 3 or more rails…is it reinforced w/wire, if so,
what kind of wire, chicken/field/hog):
22. What type of gates (describe as you did in above question)?
23. Can the gate be opened by children?
24. If you don’t have a fenced-in yard, how will the animal be exercised and allowed to eliminate?
25. Who will supervise outdoor activities?
26. Do you have (check all that apply): Pet door Kennel run Dog house Stake Tie-out or cable-run
Crate None
27. Do you have a swimming pool? Yes No
a. If yes, is it fenced-in separately from the rest of the yard? Yes No
28. What member of the family will be taking the MAJOR responsibility for the care of this animal?
29. Does anyone in your family have allergies to ANY animal?
30. Has anyone in your household had an issue with impulse control?
32. What are your plans for this animal?
(a) Protection/guard (b) Companion (c) Child’s pet (d) Pet therapy (e) Agility/fly ball
(f) Obedience (g) Herding (h) Ranch work (i) Other(explain):
33. Have you ever trained a dog in obedience classes?
a. Are you planning on taking your adopted dog to an obedience class? Yes No
34. Have you ever sold, given away or surrendered a pet? Yes No
a. If so, please provide details of situation:
35. How much time are you willing to give the dog to adjust to its new environment & family members?
36. This dog may not be housebroken. Are you willing to take the time to work with the animal?
37. For this adoption to be approved, it is required that you promise to always keep this animal on-leash before you open your front door, or whenever exercising your best buddy outside of a secured fenced-in area…do you agree to this stipulation?
38. Will the animal live in the home?
a. If not, where?
39. What type of shelter will be provided when the dog is outside (doghouse/patio/decking overhang, etc.)?
40. Where, exactly, will the animal sleep at night and be kept when there is no one at home (i.e., crated, free roam of home, laundry/kitchen area, fenced-in yard, etc.)?
41. On the average, how long will the animal be left alone during the day?
42. What is the activity level of your household?
Busy-visits by friends, meetings, children, parties at home Moderate-normal comings and goings
Noisy-TV, stereo, machinery, tools, kids playing Quiet-homebodies, few guests
43. Do you believe in dog crates?
44. If you had to move & your new landowner does not allow pets, what will you do with your companion animal?
45. When you go on vacation, will your pet accompany you or who would care for it?
46. Under what condition(s) would you consider giving up your companion animal?
47. Who is the veterinarian you currently use, or used for your previous animal’s health issues (IF used within past 5 yrs.): animal hospital’s name/vet’s name:
OR, vet’s name, address and tele# for the vet you plan to use (have you asked your dog owner friends who they would recommend to you?)
a. What type of heart worm prevention do you use?
48. How will your animal travel to the vet, or other places (i.e., crated, doggie seat belt, loose in a car/van, tethered or in crate or in box in bed of truck?):
49. May we call your vet and inquire as to your previous/current pet’s health care? Yes No
a. If not, why?
50. Are you willing to allow an H4S’s representative to periodically visit your home? Yes No
a. If not, why?
51. List NAMES & EMAIL addresses of 3 NON-RELATED personal references, whom you have known for at least 3 years, &/or whom may be familiar with your pet ownership history:
52. If you have a disability or special needs, please be sure to let us know, here; this will help us find the BEST companion for you and your needs (if your disability is not disclosed to H4S, then we reserve the right to deny this adoption at ANY time; even at the time of delivery, when you will forfeit your deposit). NO answer? Then, we will consider this application INCOMPLETE.
53. What arrangements have you made for your pet, if you could no longer care for them (i.e., moving overseas, extended hospital stay, nursing care facility, death)? NO answer? Then, we will consider this application INCOMPLETE.
53. Finally, please tell us a little about yourself and why you feel you could provide a good home for a rescued companion animal.
We reserve the right to refuse the adoption of any companion animal to anyone.
ANY FALSE INFORMATION MAY RESULT IN THE NULLIFICATION OF THIS ADOPTION!
