Dog / Puppy Adoption Application All applications are subject to review by the Adoption Committee. Completion of this application does NOT guarantee an adoption. All items marked with an asterisk must be provided. Please enter NA to items that may not pertain to your situation. Step 1 of 5 20% Pet's Name*Animal IDDog or Puppy*DogPuppyYour Name*FirstLastApplicant's Date of Birth* Address*Street AddressAddress Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZip CodePreferred Phone*Second PhoneThird PhoneEmail* Have you adopted from an animal adoptive group before?*YesNoIf Yes, which one?Do you still have the pet?YesNoIf No, why?Are you adopting for:*YourselfImmediate FamilyFriend / RelativeChildBusinessOtherOtherHow many people live in your home? *Number of children? *Ages?Does anyone in the household have animal allergies? *YesNoWho?Why are you adopting a Dog? (check all that apply): *Family PetGiftChild's PetCompanion for another petAdult CompanionOtherOtherWhich veterinary clinic do you use? What is their phone number? *Enter "N/A" if this question does not apply to you currently. Please check applicable living situation (all that apply):*Own HouseOwn Mobile HomeOwn Condominium / TownhouseRent HouseRent Mobile HomeRent Apartment/TownhouseRent DuplexRent DormLive with RoommateLive with Parent / Guardian in their homeRent to OwnIf you rent, landlord / complex name?*FirstLastIf you rent, landlord / complex phone number?*If you have a roommate, list nameFirstLastIf you live with parent/guardian in their home, list nameFirstLastOn average, how many hours per day is someone at home on weekdays (excluding sleeping hours)?*On average, how many hours per day is someone at home on weekends or days off (excluding sleeping hours)?*What will you do with your dog when you must be out of town?*Dog’s / Puppy's primary living quarters will be:*InsideOutsideBoth EquallyPlease explain the details of where your pet will be living. *If you plan on housing your pet outside for any length of time, please describe the kind of containment and/or shelter you have prepared for the dog.*If Outside, where will the pet stay while you are away from home for work or school?*Loose OutsideConfined in Garage / BarnNot ApplicableIf Inside, where will the pet stay while you are away from home for work or school?*Loose in HouseConfined to a roomBasementCratedNot ApplicablePlease describe what you feel are the characteristics of the ideal dog for you/your family.*What is your definition of disciplining a dog?*Do you plan to spay/neuter?*YesNoAlready AlteredIs your yard fully fenced?*YesNoIf Yes, fence material?If Yes, fence height?How many years do you plan to keep this dog / puppy?*Have you ever raised a puppy before?*YesNoNot ApplicableAre you prepared to deal with the cost of both routine vet care (e.g. annual shots, worming) and non-routine emergency vet care, especially as the animal gets older? *YesNoIf Yes, how long?*Do you plan to crate your pets?*YesNoAre you prepared to deal with the cost of both routine vet care (e.g. annual shots, worming) and non-routine emergency vet care, especially as the animal gets older?*How much do you expect to spend on a dog annually (including food, vet care, extras)?*$100 - $200$200 - $400$400 - $600More / otherIf More / Other, How Much?What situation/problem would force you to give up a dog? *Pet Behavior ProblemsMovingBirth of ChildDivorceOwner Illness / DeathFamily AllergiesNew Family Member / Signnificant OtherLifestyle ChangeOtherOtherIf you had to give up your pet, would you?*Give it awayTake it to the nearest shelterSell itReturn it to ACSTurn it loose to find a new homeOtherOtherPlease list 3 references not living with you. Only 1 may be a family member. All references must be 21 years or older. Please list a phone number for each reference & your relationship to each reference.*Name, Relationship, Phone - Please list one reference per line Begin: Start of your animal historyHow many pets have you owned in the last 10 years?*12345First animal's name / sex?First animal's breed?First animal spayed / neutered?YesNoFirst animal's age when acquired?First animal's current age?First animal still a family member?YesNoIf first animal is deceased, at what age?For first animal, what happened if not still owned?First animal's health / behavior problems?Second animal's name / sex?Second animal's breed?Second animal spayed / neutered?YesNoSecond animal's age when acquired?Second animal's current age?Second animal still a family member?YesNoIf second animal is deceased, at what age?For second animal, what happened if not still owned?Second animal's health / behavior problems?Third animal's name / sex?Third animal's breed?Third animal spayed / neutered?YesNoThird animal's age when acquired?Third animal's current age?Third animal still a family member?YesNoIf third animal is deceased, at what age?For third animal, what happened if not still owned?Third animal's health / behavior problems?Fourth animal's name / sex?Fourth animal's breed?Fourth animal spayed / neutered?YesNoFourth animal's age when acquired?Fourth animal's current age?Fourth animal still a family member?YesNoIf fourth animal is deceased, at what age?For fourth animal, what happened if not still owned?Fourth animal's health / behavior problems?Fifth animal's name / sex?Fifth animal's breed?Fifth Animal spayed / neutered?YesNoFifth animal's age when acquired?Fifth animal's current age?Fifth animal still a family member?YesNoIf fifth animal is deceased, at what age?For fifth animal, what happened if not still owned?Fifth animal's health / behavior problems? End: Finished with your animal history Although I understand that every animal adopted has been inspected and its history reviewed, I appreciate that you can make no warranty in regard to the pet and that you can give me only such information as you have received with regard to the pet. If, for any reason, I am not able to care for my adopted pet, I will contact the Animal Care Society for acceptance Into the Center and re-adoption. The Society will determine whether or not the pet can be accepted for re-adoption. If the Animal Care Society demands the pet's return for any reason, I agree to promptly return the pet to the Center. I shall be personally responsible for the humane care and control of the pet, and l agree that your agent shall be allowed to see the pet at any reasonable time. I further understand that any donation I have given to the Animal Care Society is a donation towards its work in caring for pets. I give the Animal Care Society my permission to obtain information from veterinarians who have seen/treated my pets.Certification Acknowledgement and Acceptance*I agree to Certification terms and conditions listed above. I CANNOT abide by the Certification terms and conditions listed above.