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May 19, 2012 12:00 pm
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Home
•
Adopt
•
Dog Application
Dog Application
1. Name of Dog
*
2. Date
*
3. Name
*
First
Last
4. Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
5. Phone
*
Enter phone number as (###)###-####, no spaces
6. E-mail Address
*
7. Driver’s License Number
8. Date of Birth
*
9. Occupation
10. Place of business
11. Please check one:
Own
Rent
Live with parents
Other
12. Type of residence (house, apt, etc.)
13. If other, please explain:
14. Landlord’s name and telephone number, if applicable:
15. How long have you been at your current address?
16. If answer to above is less than 1 year, please give previous address:
Street Address
City
State / Province / Region
Zip / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
17. If applicable, how many children do you have?
18. What are their ages?
19.How many adults live in your home?
20. Please list the animals you have owned in the past 5 years and their names, breeds, ages. Are they sterilized, currently on medications? What happened to the animals?
21. Please list the name of your current veterinarian
22. Address
23. Phone
24. I am adopting this dog (check all that apply)
Companion
Gift
To Breed
For a Child
Guard Dog for a home
Guard Dog for a Business
To Use for Hunting
25. Does everyone in your household want a dog? If not, please explain:
26. Who will be assuming responsibility for this dog?
27. Do any members of your family have allergies to animals?
Yes
No
28. If yes, who?
29. This dog needs to get along with
Other dogs
Cats
Other animals
N/A
30. If other, what type?
31. I prefer a:
Male
Female
Either
32. The size of dog I prefer is:
Small
Medium
Large
Lap dog
Any
33. I have ____ indoor dogs; ____indoor/outdoor dogs; ____cats, other pets, livestock.
34. When I am not at home, or not able to supervise my dog, my dog will be:
Loose in the house
In the yard
In the garage
In a room in the house
Crated in the house
36. When it comes to housekeeping I am:
Very particular
Particular
Easygoing
37. I have:
A fenced yard
A stationary tie-out
An outdoor run
Invisible fencing
A dog house
38. My ideal dog would be...
39. Bad dog habits that I just can’t tolerate are
40. Do you plan to spay or neuter your dog?
Yes
No
41. If No, why not?
42. Do you plan/Are you willing to take your dog to obedience school?
Yes
No
43. Are you willing to take responsibility for this dog for the next 10-15 years?
Yes
No
44. What provisions will you make for this dog should you become unable to care for it?
45. When it comes to relating to dogs, I tend to be more
Easygoing (we don’t have many rules)
Moderate (we may not always follow the rules)
Strict (we stick to rules)
46. Someone in my home is nervous or unsure of dogs:
Very (e.g., bitten as a child)
Somewhat (has had little or no experience)
No
47. The noise/activity level in my home is usually:
Low
Medium
High
Please include one reference. The reference should not be an immediate family member.
48. Name
First
Last
49. Address
Street Address
Address Line 2
City
State / Province / Region
Zip / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
50. Phone
51. Relationship
52. How did you hear about the Friends For the Dearborn Animal Shelter?
Off-site adoption event
Friend/family member
TV
Newspaper
Radio
Website
Event
Other
53. What Website, Event, or Other...
54. Other comments you may have:
**By clicking submit, I certify that all information is true and complete and that Friends For the Dearborn Shelter (FFDAS) is authorized to gather whatever information FFDAS considers necessary and appropriate for adoption of any animal. All questionnaires must be complete. FFDAS reserves the right to deny adoptions.
Phone
This field is for validation purposes and should be left unchanged.
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