CANINE
Adoption Application
Adopting a pet is a lifetime commitment. Dogs can live an average of 12 to 15 years.
Animal Name____________________ Case# _________________ Breed _____________________ Today’s Date ________________
Last Name: ___________________________________ First Name: ________________________________
Address:_________________________________________ City:________________________ State/Zip:_______________________
Primary Phone:_______________________Secondary Phone:_____________________ Email________________________________
Place of Employment:_____________________________________ Work Phone:__________________________________________
1. Where do you live? House Condo Apartment Trailer Student Housing Military Housing Other_____________
2. Do you: Own Rent Live with Parents/Relatives Live with Friends
2B. Length of Residency:_______________
3. Please give Landlord or Homeowner’s Name and Phone Number:________________________________________________
4. How many people including yourself live in the home?_________
3B. Please list everyone living in your home.
Name
5.
6.
Phone Number
Allergic
to Dogs?
Y N
Y N
Y N
Y N
Why do you want to adopt a dog? Companion
Is this your first experience with a dog? Y N
8. Do you plan to use any of the following:
9. Do you have a fenced in yard?
Y
N
Allergic
to Cats?
Y N
Y N
Y N
Y N
Over 18
years old?
Age if younger
than 18.
Live there
full time?
Y N
Y N
Y N
Y N
Guard Dog Breeding Family Pet Business Gift Hunting
7. Who will be responsible for the dog? ________________________
Outside Kennel
Runner
Chain
Tie Line
Dog House
10. If yes, what is the fence height? ___________________________________
10. Where will the dog sleep? ___________________________ 11. What will you feed your dog?_______________________
12. How many hours per day will the animal be without human companionship? ______________________________________
13. Do you have any health conditions that could restrict your ability to care for the animal? _____________________________
14. What will you do with your dog in the event that you:
a. Are unable to care for your dog? _______________________________________________________________________
b. Separate from your significant other? ___________________________________________________________________
c. Move? ____________________________________________________________________________________________
d. Go on vacation? ____________________________________________________________________________________
15. If necessary, what methods will you use to housebreak your dog? _______________________________________________
16. How will you discipline your dog? _________________________________________________________________________
17. Are you willing to seek obedience training for this dog if necessary? _________ Why Not? ___________________________
18. What will you do if your dog starts chewing on unwanted areas like furniture or carpet? _____________________________
19. What will you do if your dog’s behavior suddenly changes (lack of appetite, lethargy, etc.)? ___________________________
20. Do you pre-adoption and post-adoption follow up calls, e-mails and/or home checks?
Y
N
21. Do you have now, or did you have in the last 5 years, other pets?
Y N 22. If yes, please list below:
Have
Species
Name
Breed
Age
Sex
Fixed
Declawed Up to Date
Now?
on Shots?
Y N
Cat Dog
M F
Y N
Y N
Y N
Y N
Cat Dog
M F
Y N
Y N
Y N
Y N
Cat Dog
M F
Y N
Y N
Y N
Y N
Cat Dog
M F
Y N
Y N
Y N
23. For the pets no longer in your care, where are they now and what happened to them?
________________________________________________________________________________________________________
24. Have you ever surrendered an animal to a shelter or rescue?
Y
N
24a. Which one?___________________________
25. What were the circumstances? ___________________________________________________________________________
26. Do you have now, or did you have recently, a veterinarian?
Y
N
27. Vet’s Name & Phone Number: ____________________________________________________________________________
28. If you don’t have a vet reference, please list 2 personal references that can describe your experience with pets.
Name_________________________ Phone Number __________________________ Relation to you __________________
Name_________________________ Phone Number __________________________ Relation to you __________________
29. How did you hear about us? Adoption Event/Fundraiser
Internet
Brochure/Flyer
Family/Friend
Media
Walk-in
Returning Customer
Other: ___________________
I certify that all of the above information is true. I hereby authorize release/disclosure of any records and/or other pertinent
information including employment verification, proof of tenancy and veterinary/personal references. I understand that any
false information given on this application will automatically disqualify me from adopting a pet at this shelter. The shelter
reserves the right to deny any application it deems unsatisfactory.
Signature____________________________________________________________ Date ________________________________
CCAS Rep Accepting App: _______________________ Date: ___________________
Approved for Adoption by: ______________________ Date: ___________________
Denied for Adoption by: ________________________ Date: ___________________
Reason for Denial: _________________________________________________________________________________________
________________________________________________________________________________________________________
Extra Notes:
________________________________________________________________________________________________________
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