| Name_________________________________________Date___________ Phone(H)___________________________(W)_______________________ Street________________________City_____________State______Zip____ E-mail Address__________________________________________________ Do you own rent house townhouse apt. mobile home farm Landlord's name & number_____________________Pet's allowed Y N Your occupation/source of income_________________________________ Employer/Address______________________________________________ For whom do you want this dog?__________Why?____________________ How long do you intend to keep the dog?____________________________ How many adults in the household?______Children?_______Ages_______ Does anyone in the household have allergies? Yes No IDENTIFY PETS IN YOUR HOUSEHOLD: Cat/Dog/ Declawed Age Spayed/ Last Goes Time Other(Specify) Neutered Vaccinated Outdoors Owned ___________ Yes No ____ Yes No _________ Yes No ____ ___________ Yes No ____ Yes No _________ Yes No ____ ___________ Yes No ____ Yes No _________ Yes No ____ PETS OWNED IN THE PAST(NO LONGER WITH YOU): Cat/Dog Declawed Age Spayed/ Went Time Why no longer Other(specify) Neutered Outdoors Owned with you ___________ Yes No ____ Yes No Yes No ____ ___________ ___________ Yes No ____ Yes No Yes No ____ ___________ ___________ Yes No ____ Yes No Yes No ____ ___________ Do you have a fenced yard? Yes No If yes,what kind_________________ If the dog needed prescription food and/or daily medication, would you be willing and able to bear the added expense and time required? Yes No How long have you been at your present address?___________________ Are you planning to move in the next six months? Yes No What would you do with the dog if you moved?______________________ How frequently do you travel for business or pleasure?________________ Who will care for the dog when you travel, or in the case of emergency requiring your extended absence?__________________________________ Your work schedule(days and hours)______________________________ Are any adults at home during the day? Yes No Who will be responsible for feeding/watering the dog?_________________ If your family unit changed(marriage,divorce,new baby)would you keep the dog? Yes No Under what circumstances would you need/want to give up a pet? ___________________________________________________________ Please describe any characteristics you are looking for in a dog_________ _________________________________________________________ Where will the dog stay during the day?_____________night?__________ Where will dog eat?________ If the dog gets lost, what steps would you take to find it?______________ ____________________________________________________________ What will you do if your new dog doesn't get along with your current pet? ____________________________________________________________ Your dog may take two months or more to adjust to it's new home. Are you willing to allow time for the adjustment? Yes No If no, why not?_______________________________________________ Will you allow a Save-A-Life representative to conduct a pre- and/or post adoption home visit? Yes No How did you hear about Save-A-Life?____________________________ Name & number of veterinary____________________________________ Signature_____________________________________Date____________ |