| 1. Name(s) of dog(s) you're interested in 4 |
|  Do you want to adopt or foster this / these dog(s)?  Adopt  Foster |
| 2. Your name 4  Your spouse's / partner's / roommate's name 4 |
| 3. Your home street address 4 |
|  City 4  State 4  Zip 4 |
4. Contact Information:  Home phone (with area code) 4  Cell phone (with area code) 4  Work phone (with area code) 4  
Primary email address 4
Primary email address (type again)4
Additional email address(es)4
|
|  Best time to reach you (check all that apply): Morning  Afternoon  Evening |
| 5. Your occupational status (check all that apply): |
|  Employed full-time  Employed part-time  Retired/not employed  Full-time student  Part-time student  Active military  Military reserve |
| 6. Your spouse's / partner's / roommate's occupational status (check all that apply): |
|  Employed full-time  Employed part-time  Retired/not employed  Full-time student  Part-time student  Active military  Military reserve |
| 7. Do any children live with you or visit you regularly? |
|  Yes  No |
|  If yes, list the gender and age of each below (e.g., boy, 5; girl, 10). |
|   |
| 8. Do you own or rent your home? |
|  Own  Rent |
|  If renting, please provide the name, address and telephone number of your landlord: |
|  Landlord's name4   Phone number (with area code)4  |
|  Street address4  |
|  City 4  State 4  Zip code 4 |
| 9. Is your yard completely and securely fenced? |
|  Yes  No |
|    Do you have any other way(s) to keep a dog on your property? (Check all that apply.) |
|  Invisible/radio fence  Kennel  Pen  Cable run  Other (explain) 4 |
10. Please complete the following information for each pet you currently own.    If you have more than 3 pets, please list their information in the "additional information" box at the bottom of this application. |
|    Pet #1 |
|  Name4  Species (e.g, cat, dog)4   Breed4  |
|  Age4   Sex4   Weight4  |
|  Spayed or neutered? |
|  Yes  No |
|  Vaccinations current? |
|  Yes  No |
|  Currently on heartworm prevention (dogs only)? |
|  Yes  No |
|    Pet #2 |
|  Name4   Species4   Breed4  |
|  Age4   Sex4   Weight4  |
|  Spayed or neutered? |
|  Yes  No |
|  Vaccinations current? |
|  Yes  No |
|  Currently on heartworm prevention? |
|  Yes  No |
|    Pet #3 |
|  Name4   Species4   Breed4  |
|  Age4   Sex4   Weight4  |
|  Spayed or neutered? |
|  Yes  No |
|  Vaccinations current? |
|  Yes  No |
|  Currently on heartworm prevention? |
|  Yes  No |
11. Please provide your vet's contact information.  (Complete this for any pet you have owned within the past year, even if you don't own a pet right now. |
|  Name of vet or vet clinic4  |
|  Vet's street address4  |
|  City4   State4   Zip4   Phone number (with area code)4  |
| 12. If you do not currently own a dog, have you ever owned one? 
|
|  Yes  No |
|  If yes, how long ago?4  |
| 13. Please tell us why you want to adopt or foster a dog at this time: |
|   |
| 14. Are you looking for a dog that will stay mainly indoors or outdoors? |
|  Indoors  Outdoors |
| 15. Are you willing to consider any other dogs, whether currently listed on our website or not? 
|
|  Yes  No |
|  If yes, please tell us what qualities and characteristics you are looking for or will consider:
|
|  Age (select all that apply): |
|  Under 6 months  6 months to 1 year  1 to 3 years  3 To 5 years  5 to 7 years  7 years or older |
|  Gender (choose one): |
|  Male  Female  Doesn't matter |
|  Size (check all that apply): |
|  Toy (under 10 lbs.)  Small (10 to 25 lbs.)  Medium (25 to 50 lbs.)  Large (50 to 75 lbs.)  Giant (75 lbs. or more) |
|  Breed(s):  |
|  Coat (e.g, short or long; smooth or rough; no preference):  |
|  Would you consider a dog with special needs or a disability? |
|  Yes  No |
|  Other qualities or characteristics of importance to you (e.g., personality, playfulness, energy/activity level, leash-trained, housebroken, etc.): |
|   |
| 16. Would you consider adopting / fostering more than one dog? |
|  Yes  No |
| 17. Why do you feel you are or will be a good dog owner or foster parent? |
|   |
| 18. May we visit your home as part of our screening process?
|
|  Yes  No |
19. Please provide the name and telephone number of someone NOT RELATED TO OR LIVING WITH YOU who can talk about your ability to care for a pet.   Please do not list your vet. We require a personal reference in addition to your vet. |
|  Your reference's name4  |
|  Relationship to you (e.g, friend, neighbor, coworker) 4 |
|  Phone number (with area code)4   This is your reference's (check one) Home number  Cell number  Work number |
20. Additional information. Use this space if there is anything else you would like to tell us. Also, if you have more than 3 pets, list additional pets' information here. |
|   |
|  21. Do you certify that you at least 21 years old and financially able to care for this dog? |
|  Yes  No |