Contact Information Contact Name First Name Last Name Primary Phone Secondary Phone Address info Email Address City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Date of Birth State Driver’s License/ID Number Resident Information Do you: Own Rent Other… Enter other… Name and contact phone number for property owner or landlord: Do you live in: House Apartment Mobile Home Other… Enter other… How long have you been at your current address? Less than 6 months 6 months - 1 year 1 - 5 years 5 - 10 years More than 10 years Other… Enter other… If less than 6 months please list previous address Address City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Will you be moving soon? Yes No Please list all current household members (including children) names & their ages residing in your household Do any members of your household have allergies to animals? Dog Application Information Are you applying for a particular dog? Yes No If yes, please enter the Shelter ID number you see on our web site for the dog: Where will this pet be kept during the day? Where will this pet be kept while you are at work? Where will this pet be kept in the evening? Will this pet primarily be: Indoors Outdoors In/Out Other… Enter other… How will you confine your new pet on your property? Why do you want to adopt a pet? Who will be the primary caretaker of this pet? Who are you adopting this pet for? How much do you anticipate spending yearly on a pet you adopt? If your adopted pet becomes destructive or is not housebroken, what would you do? Under what circumstances would you not keep this pet? If you move, what will you do with this animal? Please list the pets that you currently own or reside at your home. Include type of animal, male/female, age, if current of vaccines, where currently licensed, license number (if required in your jurisdiction) and where did you get this pet? Which of the following describes the activity level you are looking for in a dog and that would fit your lifestyle? Low (Occasional walks) Moderate (Frequent walks, run/hike occasionally) High (Run often, hike regularly) Other… Enter other… Please list the types and breeds of pets you've owned in the last five years. Include age, how long you owned, and where the animal is now. Do you have a veterinarian currently? Yes No Please provide your veterinarians name and address. What type of dog are you most interested in? Where did you hear about our adoption program? Where did you hear about our adoption program? - Select -Friends or FamilyRescue group or other shelterVeterinarianCounty WebsiteSocial mediaI’ve adopted here before Walk in/drive byOther… Enter other… Which one? Which one? - Select -FacebookInstagramTwitterOther… Enter other… I understand that if I don't finalize payment my application will not be reviewed or accepted. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit and Pay
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