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Name(s)

Date of Birth

Name of Spouse or Roommate

Address

City State Zip

Home Phone

Cell Phone

Work Phone

Driver's License Number

Email Address

Place of Employment

Employment Address

Dog that I want to adopt:

What is your reason for wanting to adopt this dog? (family pet, child’s pet, watchdog, hunting dog, companion, companion for other pet, other)

Is your residence a house, apartment, condo, or mobile home?

Do you own or rent your residence? If you rent, please provide your Landlord’s name and phone number.

How many people live in your household? Please provide the number of adults, number of children, and ages of children.

How many pets have you owned in the past five years?     Dogs     Cats    Other
Where are these pets now? (Still with you, died of natural causes, put to sleep, sold, ran away, given away, etc.)

If you currently own pet(s), please list type, breed, and age of each.

Your veterinarian’s name and phone number:

Are all your current pets (if any) spayed/neutered? If not, why?

Are your current pet’s (if any) vaccinations up to date?

Do you know how to protect your dog from heartworms?

Do you think it is important to take your dog to the vet for full preventative and medical care at least once a year?

What do you expect annual pet care (vet care, medication, vaccines, food, etc.) to cost?

If this dog develops a serious medical condition that becomes expensive, what would you do?

Who will be responsible for the daily care of this dog?

Where do your current pets (if any) stay when home alone?

What provisions are made for a pet when you are on vacation?

Is there a yard available where this dog will reside? If so, is it fully fenced without gaps?
What is the height of the fence? Is there a doghouse or shelter in the yard?

Where will this dog stay? (inside, outside, both)

How many times a week do you anticipate walking this dog on a leash?

How much time will this dog spend alone each day?

Where will this dog sleep?

Have you ever had a pet that was struck and/or killed by a vehicle?

Do you have a swimming pool?

What plans do you have for obedience training? (classes, video, books, in-home lessons, none, other)

Have you ever had a serious behavioral problem with a pet? If yes, please explain.

How will you resolve behavior problems that may appear with this dog?

If necessary, what procedures will you use for housebreaking this dog? (crate training, newspaper, rubbing nose, swatting with newspaper, outside only, other)

Would you allow UCHS to visit your home to verify where this dog will be kept?