TEST: Adoption Application - Dogs - Humane Society of Pulaski County

The Humane Society of Pulaski County (HSPC) strives to assure that the homes in which our dogs are placed meet the highest standards of animal care. We reserve the right to deny any adoption request.

Please Acknowledge*

I certify that I am at least 21 years old, and can provide identification for proof of age.

Read and Accepted

Name & Contact Info*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Date of Birth*

(You must be 21 to adopt)

Email Address*

Daytime Phone*

Alternate Phone

Employer*

Length of Employment?*

What is the name of the dog you want to adopt?*

How did you learn about this dog?*

Is this dog to be a gift for someone?*

Have you ever had to give up/surrender ownership of a pet?*

If yes, why?

Would you object to a home visit before adopting?*

If yes, why?

We reserve the right for an authorized representative to make random and unannounced visits and/or follow up to assure adoptions are going well. Is that acceptable to you?*

ANIMAL INFORMATION

Have you had any other animals in the past ten years?*

If so, what happened to them?

Please list dogs, cats, or other animals currently in household which the adopted dog will be living and interacting with:

Name	Type (Dog, Cat, etc)	Age	Spayed/Neutered? (Y/N)	Vaccinations current? (Y/N)	Indoor or Outdoors?	Temperament

Click the (+) at the end of the line to add multiple pets

Would you adopt a dog that has health issues?*

No
Yes

What is the veterinary clinic with your pets most recent information/records?*

Will your adopted dog be:*

Indoors
Outdoors
Indoor/Outdoor

How many hours per day (on average) will this dog be without human companionship?*

Where will the dog be kept when it is alone during the day?*

Where will the dog be kept during the night?*

Are you willing to housetrain your puppy or dog, if not already housebroken?*

(Note that even previously house-trained dogs make require acclimation to their new home)

What planned activities do you have for this dog?*

(Hold down the CTRL key to select multiple options)

Temperament Desired?*

How do you plan to address behavior challenges/issues with this dog?*

Do you understand the need for patience with problems like chewing, digging, barking, and/or soiling the carpet?*

HOUSEHOLD INFORMATION

Do you live in a*

Do you own or rent your home?*

Do you live with relatives or extended family members?*

If so, who?

If renting, does your landlord allow pets?*

Describe any size or breed restrictions where you rent.

What is the name and telephone number of your landlord?

Do you have a fully-fenced yard?*

Please describe your fence (size, height, material)

What type of shelter (if any) is in the fenced yard?

Do you understand that routine expenses for a dog (vaccinations, heartworm preventative, food, rabies shots, etc) may be $300-$600 per year (or more)?*

FAMILY INFORMATION

Number of adults in your household?*

Please enter a number greater than or equal to 0.

Number of people home during the day?*

Please enter a number greater than or equal to 0.

Number of children in your household?*

Please enter a number greater than or equal to 0.

Ages of Children?

Are there any children or pets who regularly visit your home that are not listed on this form?*

If so, please share the details (i.e. ages and frequency)

Who will be primarily responsible for the care of the new pet?*

Has everyone in the family agreed to adopt an animal?*

Is anyone in your household allergic to animals?*

Is there anything else you'd like for us to know?

PLEASE READ AND ACKNOWLEDGE THE FOLLOWING

Adoption is a Life Long Commitment*

Adopting a companion animal is a great responsibility. I will be sharing my life with a pet who is totally dependent upon me for food, shelter, veterinary care, and love. Animals should be closely supervised when they are with children. I am responsible for checking to see if the city in which I live requires animals to have a city license as well as other local laws, and I will obtain any required license and comply with all applicable local ordinances regarding this dog. I will keep the HSPC identification tag in order to help identify the dog if it is lost. I understand the need also for a tag with my phone # on it, if the dog gets lost. Except for medical reasons and extraordinary circumstances, HSPC does not provide refunds for adoption fees.

Read and Accepted

Acknowledgement of Information About This Pet*

I have clicked on this pet's photo and have read the biographical information shared about this pet.

Read and Accepted

Acknowledgement of Medical Care and Responsibility*

I understand the need to keep my dog current on annual vaccinations, preventative care, and flea and tick preventative.

Read and Accepted

Liability Waiver*

I understand that the HSPC cannot guarantee the health, temperament, or training of the animal and I hereby release the HSPC from all liability once the animal is adopted.

Read and Accepted

Please Acknowledge*

The information provided in the adoption request questionnaire is true and correct and providing false information is sufficient reason for the Humane Society of Pulaski County to reclaim the animal or animals.

Read and Accepted

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TEST: Adoption Application – Dogs

Adoption Application (Dog)

ANIMAL INFORMATION

HOUSEHOLD INFORMATION

FAMILY INFORMATION

PLEASE READ AND ACKNOWLEDGE THE FOLLOWING

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