Online Dog Adoption Application Form

Contact Information

Full name:*

Occupation:

Address:

How long at this address:

Daytime Phone:

Evening Phone:

Best time to call:

Email address:

Family & Housing

How many adults are there in your family (their relationship to you)?

How many children (ages)?

What type of home do you live in single family, town home, apartment, farm, etc.?

Please describe your household:

If you rent, please give the rules governing pets and the landlord's name and number: (by providing this information you are allowing PPPR to contact your landlord please inform them of this call so they will speak with us)

Does anyone in the family have a known allergy to dogs?

Is everyone in agreement with the decision to adopt a dog?

What other pets do you have (specify type and number)?

Other Pets

Do you have time to provide adequate love and attention?

Are these pets up to date on vaccines?

Are these pets spayed/neutered? If not,why?

Have you every surrendered a pet? If so, why?

Have you ever had a pet euthanized? If so, why?

Have you ever lost a pet to an accident?

How do you discipline your pets and why?

Veterinarian

Do you have a regular veterinarian?

Veterinarian's name:

Clinic Name:

Clinic Address:

Clinic Phone:

(Providing PPPR with this information you are allowing PPPR to call your vet. Please call your vet and ask them to authorize the release of information to PPPR.)

About the Dog You Wish to Adopt

What is your idea of an ideal dog and why?

Desired age:

Desired Size:

Desired breed:

Breed you would not adopt:

Desired sex:

Willing to adopt:

outgoing/hyper dog

dog that needs regular medication

dog that needs grooming

shy dog

dog that needs training

None of these

Where will the dog spend the day? (describe)

Where will the dog spend the night? (describe)

Number of hours (average) dog will spend alone?

Who will have responsibility for this dog's daily care?

Who will have financial responsibility for this dog?

Do you agree to provide regular health care by a Licensed Veterinarian?

Do you agree to keep the dog as an indoor dog?

When the dog goes out, how do you plan to supervise it? Fenced yard?

Do you agree to contact PPPR if you can no longer keep this dog?

Are you be willing to let a representative of PPPR visit your home by appointment?

How did you hear about PPPR?

Would you be interested in fostering?

Personal References

Please list someone who is familiar with both you and your pets.

Name:

Address:

City:

State:

Zip Code:

Phone:

Email:

Relationship (relative, neighbor, friend, etc.):

All of the information I have given is true and complete. This dog will reside in my home as a pet. I will provide it with quality dog food, plenty of fresh water, indoor shelter, affection, annual physical examination and vaccina-tions under the supervision of a licensed Veterinarian.

Upload your Signature:

Date: