ADOPTION APPLICATION

Fields marked with * are required.

 

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PERSONAL INFORMATION - PRIMARY APPLICANT
* First Name
* Last Name

Nickname
* Address
* City
* State, Country, & Zip Code
* Email Address
* Primary Phone (999) 999-9999
* Best times to call Primary

Alternate Phone (999) 999-9999

Best times to call Alternate
* Date of Birth mm/dd/yyyy
* Occupation

Spouse's First & Last Name required if applicable

PERSONAL REFERENCES (no relatives please)
* First Reference:

First & Last Name

Relationship

Phone (999) 999-9999
* Second Reference:

First & Last Name

Relationship

Phone (999) 999-9999
* Third Reference:

First & Last Name

Relationship

Phone (999) 999-9999

RESIDENCE INFORMATION
* Type of Dwelling
* How long at this address?

Your previous address if above
is less than one year:
* Do you?
* If you rent:

Do you have your landlord's
permission to have a dog?

Landlord's First & Last Name

Landlord's Phone (999) 999-9999

CONTAINMENT INFORMATION
* Do you have a fenced yard?
* If yes, check all that apply:

Fence height(s):

Fence type(s):

If Other, please specify:
* If you do not have a fenced yard:

How do you plan to handle
exercise and toilet duties?



* Are you familiar with crating?
* What do you think about crates?

HOUSEHOLD INFORMATION
* Provide the following for each person, other than applicant, who lives in your household:

First person:

Name (leave blank if none)

Age

Relationship

Occupation

Second person:

Name (leave blank if none)

Age

Relationship

Occupation

Third person:

Name (leave blank if none)

Age

Relationship

Occupation

Fourth person:

Name (leave blank if none)

Age

Relationship

Occupation

Fifth person:

Name (leave blank if none)

Age

Relationship

Occupation
* More persons not listed above?
* If yes, please identify them:
* Dog's primary caregiver:
* Has everyone above agreed
to your pursuing the adoption?

PET OWNERSHIP
* Have you ever owned any cats?
* If yes:

How many in past 10 years?

Briefly describe what
happened to the cats
you no longer have:

How many do you own now? (leave blank if none)

Are they?

Are your cats declawed?

Briefly describe how your
cats interact with dogs:
* Have you ever owned any dogs?
* If yes:

How many in past 10 years?

Briefly describe what
happened to the dogs
you no longer have:

How many do you own now? (leave blank if none)

For each dog you currently own, provide the following information:

1) Name

Age

Breed

Spayed/Neutered?

2) Name (leave blank if none)

Age

Breed

Spayed/Neutered?

3) Name (leave blank if none)

Age

Breed

Spayed/Neutered?

4) Name (leave blank if none)

Age

Breed

Spayed/Neutered?

5) Name (leave blank if none)

Age

Breed

Spayed/Neutered?

More dogs not listed above?

If yes, please identify:
* Do you have any other pets?

If yes, please list all animals that you own (other than cats or dogs):

VETERINARIAN INFORMATION
* Do you have a veterinarian?
* If yes:

Name of veterinarian

Name of organization

Address

City

State, Country, & Zip

Phone (999) 999-9999

Fax (999) 999-9999
* Are you familiar with
heartworm disease?
* Do you currently practice heartworm prevention?

If yes, what medication do you use and how often?

If no, please explain why not:

ADOPTION INFORMATION
* This application is for
* Is this for a specific dog?
* If yes, the dog's name
* Your preferences
Dog's energy level - check all that apply:


* Why you prefer this breed:
* Would you consider a mix?
* Personality traits you are seeking in your new dog:
* Are you willing to do the following?

Obtain a crate for your dog?

Crate train your dog?

House train your dog?

Attend obedience classes?
* If no to any of the above, explain why not:
* What would you do if your dog bit somebody?

THE NEW DOG
* Where will your dog spend the day?

Check all that apply:






* Where will your dog spend the night?

Check all that apply:






* How many hours will your dog
spend alone each day?
* Is there someone home during the day?
* What are your work hours?
* Who will care for your dog
while you're on vacation?

OTHER INFORMATION
* Will you allow a representative of Closer to Home Animal Advocates to visit your home by appointment?

I agree to a home visit
* How did you hear about Closer to Home Animal Advocates?

Please let us know if there is any other information that you want us to consider when evaluating your application:

Additional information:
* You understand that owning a dog is a commitment for the dog's lifetime and that if you adopt a dog from Closer To Home Animal Advocates, you are affirming that you are both willing and able to make that commitment and that you can responsibly and reliably ensure the safety and welfare of the dog.

I agree with the above

Click the SUBMIT button to submit your application.