DOG
FOR STAFF/RECEPTION USE ONLY
Name of Dog applying for: _________
Date/time application was turned in:
_______________________________
: ___________
Description of animal applying for:___________________
ID#_________-_______ Animal’s Name: _________________
Sex:_______Age:_______
Spay/Neutered: Yes
No
Spay/Neuter Voucher Provided: Yes
No
Heartworm test results: n/a
negative
positive
Staff Adoption Coordinator Initials ___________
Date:_______________
PLEASE COMPLETE IN ITS ENTIRETY.
DOG ADOPTION APPLICATION (Please Print Clearly & Answer all Questions.)
The Darlington County Humane Society has the right to refuse adoption to anyone.
Applicant's Name_____________________________Driver’s License #:____________________
Local Address______________________________________________________Apt#___________
City_______________________________________State____________________Zip___________
Is your home near a busy highway or road?_______Yes ___________No
Home Phone ________________Cell Phone __________________ Work Phone ______________
Email ____________________________________________________________________________
DESCRIPTION OF RESIDENCE:
Do you Rent?________Own?_________
___House
Property owner's name:_________________________Phone____________
___Apartment
How long have you lived here?______________________________
___Mobile-Home
___Duplex
#Adults in house______#Children______Children's Ages____________
WHAT PETS DO YOU CURRENTLY HAVE IN YOUR HOUSEHOLD?
KIND
SPAY/NEUTER
KEPT WHERE?
TIME OWNED
Yes____
___
AGE
NO____
Name of pet
Dog__Cat__ | Yes___No___ | In____Out___
|___________________|__________|______________
Dog__Cat__ | Yes___No___ | In____Out___
|___________________|__________|______________
Dog__Cat__ | Yes___No___ | In____Out___
|___________________|__________|______________
Other_____ | Yes___No___ | In____Out___
|___________________|__________|______________
LIST PREVIOUS PETS
KIND
SPAY/NEUTER
WHAT HAPPENED
KEPT WHERE?
TIME OWNED
TO PET______ Name of pet
Dog__Cat__ | Yes___No___ | In____Out___
|___________|__________________|______________
Dog__Cat__ | Yes___No___ | In____Out___
|___________|__________________|______________
Revised March 2013
B. Poston

Are you at least 18 years old?______Yes_________No

What is the name of your veterinarian?______________________________________

Veterinarian's address______________________________________________________
i

IS THE VET REFERENCE UNDER ANOTHER NAME? IF SO, NAME AND
REASON:_____________________________________________________________________

How long have you used this Vet? ___________________________________________

DOES THIS VET DO EVERYTHING FOR YOUR PET OR DO YOU USE OTHER RESOURCES SUCH AS
CARA-VAN? YES( ) NO ( ) EXPLAIN:____________________________________________

Who will be responsible for the daily care/feeding of this dog?
____________________________________________________________________________

Who will financially support this dog?______________________________________

Reason for wanting this dog?________________________________________________

Where will you keep this dog?_______________________________________________

Do all members of this household WANT this dog?_____________________________

If you have young children, they need to be educated on how to interact with the
dog in order to prevent dog bites, are you able/willing to do that? ___Yes ___No

How many hours will your dog spend alone?____________________________________

If you must give up this dog, what would you do with it?_____________________

Would you object to a follow-up home visit by the Darlington County Humane Society?
Yes____
No_____
Best day/time: __________________________________

What amount of time will the dog be inside?______outside?______


If adopting an outside dog, do you have a doghouse? ______Yes_____No

If adopting an outside dog, do you have a fenced yard?_____Yes_____No
Height of fence?____________________

If adopting an outside dog, do you have a shaded area?_____Yes_____No

Do you plan to chain your dog outside?_______Yes_______No

Do you realize that an outside dog may entertain itself by digging, chewing home
items and/or escaping and wandering?
___Yes
___No
What will you do if your dog shows destructive behavior? (Digging, chewing, jumping,
tearing up plants/furniture or running off)

________________________________________________________________________________
Do you realize that you will probably have to housetrain your new puppy/dog?
____Yes____No
Revised March 2013
B Poston

Would you like information on how to housetrain a new puppy or dog?
____Yes____No

If adopting an adult dog, how many times per day will you exercise it? 1

What form of exercise will you provide for your dog? _________________________

Will you have this dog vaccinated annually, by a veterinarian, against infectious
disease?__________ Veterinarian:_________________________

Are you familiar with heartworm disease?______Yes______No

Will you maintain your dog on heartworm preventative?
_____Yes_____No

Do you realize that dogs often live longer than 10 years and are you willing to
assume responsibility for that long?______Yes_____No

How will you keep the dog confined to your property? (Check all that apply)
___House____Kennel____Fence____Chain___Patio_____Garage___Leash____Other

Where did you hear about the Darlington County Animal Shelter?
___Friend____TV___Newspaper___Relative___Radio___Billboard___Petfinder
___Internet ___Other

Have you applied to adopt from this shelter before today? ___Yes ___No
Date:________________
Pet Adopted?
Yes
2
3
No
If yes, where is this animal now? _______________________________________________
Additional notes or comments:__________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
I certify the above is true and that false information may result in nullifying this
adoption. I understand that Darlington County Humane Society will verify my references
provided above and it may take up to 96 hours for verifications to be completed and for
me to be notified of the decision. I also understand that Darlington County Humane
Society has the right to refuse adoption to anyone. I understand that no animal can be
held for me. I also understand that if for ANY reason, I can’t keep the animal adopted
from the Darlington County Humane Society, I will return it to the shelter. I
understand that I am prohibited from re-homing the animal to anyone and I must return
the animal to the shelter if I can’t continue to keep and care for the animal.
Signature_________________________________________Date_____________________________
Shelter Use Only:
Confidential Adoption Counselor Comments:
_______________________________________________________________________________________
_______________________________________________________________________________________
Application Approved _______________________
Application Denied_______________________
Signature______________________________________
Date_____________________________
Revised March 2013
B Poston