Dog Adoption Application

(Staff use) ID # ________________    ARK checked ____/____/________

In order to be considered for an adoption you must:   1) be 21 years of age   2) have the knowledge and consent of all adults living in your household   3) have a valid ID with current address   4) understand that completing this application does not guarantee adoption and that the Humane Society of Central Illinois must approve your application.

Name ___________________________________________________________________________________   Date ____/____/________

(Please print name(s) of all adults in the home)

Address _________________________________________________________________________________________________________ City __________________________________   County _______________________   State _________________   Zip Code ___________ Home Phone ______________________________   Work ______________________________   Cell ______________________________ If we may use e-mail to contact you, please include an address _______________________________________________________________ DO YOU:   Attend School _____   Work _____   Employer __________________________   Spouse's employer _______________________ DO YOU LIVE IN A:   House _____   Apartment _____   Condo _____   Dorm _____   Mobile Home _____ DO YOU:   Rent _____   Own _____   Live with Parents _____   Landlord's Name _______________________________________________ Landlord's Address _____________________________________________________   Phone _________________________ How long at current address ______________   If less than 1 year please list previous address and how long there ______________________ ______________________________________________________________________________________________________________ Please provide the following information about your household:   Number of Adults ________   Number of Children _______ Ages of children ______________________   Who will be primarily responsible for the care (feeding, grooming, exercise and training) of your new pet? ______________________________________________________________________________________________________ Why would you like to adopt a pet from us?   Please check all that apply.   Companion ______   Gift ______   To Breed ______ For a Child _____   As a Guard Dog _____   Companion for another pet _____   Other _______________________________________ How many pets do you have now:   Dogs _______   Cats _______   How many pets have you had in the last 5 years _______ Please list any pets you now have or have had in the past. If more space is needed use additional sheet.

NAME

TYPE/BREED

AGE

SEX

FIXED?

WHY YOU NO LONGER HAVE

_______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Have you ever adopted an animal from a shelter?   If yes,   Where? __________________________________   When? _________________ Are your current pets up to date on vaccinations and other necessary vet care? __________________________________________________ What veterinarian would have records (past/present)? ______________________________________________________________________ Which veterinarian do you plan to use? ________________________________________________________________________________ How much do you anticipate spending yearly on food, vet care and other expenses for your dog? ___________________________________ Do any members of your household have allergies? ______________   To what? _______________________________________________ Do you have any plans to move in the near future? _______   If at some time you do move, what will you do with your pet? _______________________________________________________________________________________________________________ How much time will this dog be alone (without human companionship)   Hours ____________   Days a week ____________ Will your dog stay:   primarily inside? ______________   primarily outside? ______________   outside only? ______________ Where will the dog be kept when home alone? ________________________________________________________________ Where will you exercise this dog? ________________________________________________   how often? ___________________ Do you have a fully fenced yard? ___________   What type of fence?   wood _____   chain link _____   other ______________ What food will you feed? ___________________________   How often will you groom/brush? _______________________ Describe how you will housebreak a dog ______________________________________________________________________________ When, or if not fenced, will you use a leash:   all the time ______   almost always ______   sometimes ______   never ______ How will you discipline or correct your dog? ____________________________________________________________________________ A dog can live well over 10 years and requires a major commitment of time, finances and emotion. Why do you feel you can make that kind of commitment at this time? ____________________________________________________________________________________ What breed or type and hair length? ____________________________________________   age __________________ Weight/size as an adult? __________________   Sex? __________   Any other specifics? __________________________

By signing below, I certify that the information given is true and correct and I recognize that any misrepresentation of facts will result in my losing the privilege of adopting a pet. I also give my veterinarian permission to release any vet care records and information about my current and past pets to the Humane Society of Central Illinois. I understand that this application is the property of the Humane Society of Central Illinois and that the Humane Society of Central Illinois has the right to deny my request to adopt.

Signature ____________________________________________________   Date _____/_____/_________ Signature ____________________________________________________   Date _____/_____/_________

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