Dog Adoption Form CONTACT INFO * Your Name * Your Email * Street Address * City * State ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming * Zip Code * Phone Number * Phone Type HomeMobileWork * Alternative Phone Number * Phone Type HomeMobileWork HOUSEHOLD INFO * Are you over 18 ---YesNo * Do you own or rent a home Rent Own * If you rent, please tell us your landlord's name and phone number * How many children live in the home and what are their ages * How many hours each day will the adopted animal be without human companionship? ADOPTION INFO * Are you interested in any particular dog(s)? If so, which one(s)? Otherwise, describe in detail the type of dog you're looking for: * Will this be your first dog? ---YesNo * Why do you want this dog? CompanionCompanion for other petHuntingBreedingProtectionGiftOther If other, please explain why you want this dog * Where will the dog sleep? Please be as specific as possible. (basement? garage? kennel? bed in the house, etc). * Does everyone living in your home know about and agree with your decision to adopt a dog? ---YesNo If not, why? * Are there times when the dog will be tied up? ---YesNo If yes, when will it be tied up? * Will you keep the dog up-to-date on vaccinations, provide proper medical care & exercise as needed? ---YesNo * Are you willing to have a representative of Pets Alive come see where the dog will be living? ---YesNo * If you move, will you take the dog with you? ---YesNo If no, please explain why not * Are you willing to take responsibility of this dog for the next 10 to 15 years? ---YesNo If no, please explain in detail * How much are you willing to spend on medical bills for your dog? NoneUp to $100Up to $500Up to $1000Up to $2000Whatever it takes What would you do if vet bills went over this amount? * Please provide one reference that is NOT your vet or someone living in your home (name AND phone number please): * Please provide your veterinarian's information - name and phone number (after submitting this form please CALL your vet & give them your permission to speak to us) : PREVIOUS PET INFO * What animals do you CURRENTLY have? Include age, sex, breed and species. * What happened to the pets you no longer have? * Are all your current pets spayed or neutered? ---YesNo * Have you ever had a pet euthanized? ---YesNo If yes, please explain further * Have you ever turned in a pet to a shelter? ---YesNo If yes, please explain the circumstances: * Have you ever applied to Pets Alive before to adopt an animal? ---YesNo If yes, when?