Application for Adoption

Name of animal you are applying for: *

Breed of animal you are applying for: *

YOU AND YOUR FAMILY

First Name: *

Last Name: *

Birthdate (MM/DD/YYYY): *

Address: *

City: *

State: *

Zip: *

Home Phone Number: *

Cell Phone Number: *

Which phone number do you prefer we call? *

Home

Cell

Other Other

Email Address: *

Employer/Occupation: *

Employers Address: *

Name of Spouse/Significant Other:

Birthdate of Spouse / Significant other (MM/DD/YYYY): *

Spouse or Significant Others Phone Number:

Spouse or Significant Others Employer and Occupation:

Please list all members of your household, their ages and relationship to you (including any children): *

If no children live in the home, will any visit on a regular basis? If yes, please provide ages of children visiting and frequency. *

No

Yes Yes

Have the children in the home (if any) been exposed to dogs? *

Yes

No

N/A

What breeds of dogs have your children (if any) been exposed to?

Do you plan on having children and/or having more children? *

No

Yes

Does anyone in your household have pet allergies? *

No

Yes Yes

If you plan on having a child or having more children, how do you plan to introduce the baby to the dog?

YOUR LIVING ENVIRONMENT

Please choose the best description of your home: *

Do you rent or own your home? *

Rent

Own

If you rent, do you have your landlords permission to have the breed you are applying for in the home?

Yes

No

Please provide your landlords name, address and phone number if you rent, if you own your home please list N/A: *

How long have you lived in your current home? (If less than 2 years please supply previous address): *

Have you or your spouse / significant other lived in a state other than PA? If yes, please list the state(s) either of you have lived: *

What will you do with the dog if you must move in the future and dogs are not permitted in your new residence? *

Do you have a fence at your current home? If yes, please describe the type of fence with respect to height, type and location. If no, please explain how you intend to properly exercise the dog you are applying for. *

Has anyone in your home ever been convicted of a crime? If yes, please explain who and the circumstances: *

No

Yes Yes

Has anyone in your home ever been accused or plead guilty to anything involving animal cruelty? *

No

Yes Yes

Is anyone home during the day? *

No

Yes

Please describe the hours during the day that the dog would be alone: *

Annually, how much do you think it will cost to own a dog? (This should include everything in a years time ie: food, veterinary care, medicines, toys etc.) *

YOUR INTERACTION WITH YOUR NEW PET

Why do you want to bring in a new dog to your home? *

Do you plan on using the crate training method with your new pet? Please provide specifics in the box below with your thoughts on crate training and how you would use it if you did: *

Does your new pet need to be housebroken prior to coming to you? *

Yes

No

Please describe how you intend on housebreaking your new pet: *

Please describe your current understanding of obedience training and why you would be able/ would not be able to attend obedience class. *

What behaviors (chewing, digging etc.) do you feel you have time to work with and change? *

We attempt to provide all adopters with an honest and thorough evaluation of temperment on every dog in our care. Do you realize that often times a complete history of the dog may not be known and you could encounter some behavioral problems? If so, how will you deal with these problems? *

What will you do if your new dog starts exhibiting undesirable or destructive behaviors? *

How do you feel about dogs lying on furniture or sleeping in bed with you? *

What behaviors do you feel would cause you to return a dog? *

How do you plan to introduce the animal to the new environment and possibly other animals? *

How do you plan on showing the dog that you as the owner are the pack leader? *

VETERINARY CARE

Please list all current pets and their respective information including: Species (dog, cat, etc.), Name, Age: *

Which veterinary practices / procedures do you currently use for your pets? Please check all that apply: *

What brand of flea and tick medicine and/or heartworm medicine do you currently use: *

Please list all previous pets and their respective information including: Species (Dog,cat etc.), Name, Age at Death, Cause of Death. *

Please list your veterinarians contact information below. Be sure to include the name, address and phone number of the practice. If you do not currently have a veterinarian, but used one in the past, please list the veterinarian you used to use. If there are multiple vets, please include a time period. **Please contact your veterinarian immediately and allow them to release information to Zoe's House. If you fail to do this, it can lengthen the application process. Thank you! *

Do we have your permission to contact your veterinarian? *

Yes

No

Have you ever surrendered or given up one of your previous pets? *

Yes

No

If you have surrendered or given up a previous pet, why?

BEFORE WE ADOPT

Are you familiar with your local leash/licensing laws? *

Yes

No

We will ask you to agree to keep your dog up to date on vaccines and on heartworm preventative year-round due to the increasing prevalence of heartworm in our area. Is this acceptable to you? *

Yes

No

Please list two personal references that are not family members. (Please include name, address, phone, relationship to you and years known.) *

Please list a personal reference that IS a family member. (Please include name, address, phone, relationship to you and years known.) *

How did you hear about our organization? *

Additional information / notes: *

You are attesting that all information on this form is correct to the best of your knowledge. You also affirm that you are prepared to share your life with a dog for many years; a dog that will totally be dependent on you for food, water, shelter, love, affection, safety and veterinary care. By placing your name and date below, you are electronically signing this document. *