Name of dog or type of dog for adoption *
How did you hear about the adoptable dogs at The Animal Haven?
Name(s) *
Home Phone
Cell Phone *
Email *
Occupation *
Employer Name
Employer Address
Employer Phone Number
Landlord's Name & Phone Number
How long have you lived at this address? *
What would you do with your pets if you moved? *
How many people live in your home, including yourself? *
Please provide the names and ages of all those living in your home, including yourself: *
If your family situation were to change (e.g., divorce, new baby, marriage), would you keep your pet(s)? *
Please list all of your current and/or previous pets starting with the most recent: *
With respect to each pet listed above, state the following: the pet's name, age, breed, sex, whether spayed/neutered, whether indoor and/or outdoor, and whether alive or deceased *
With respect to each of your previous pets, state whether the pet was lost, given away, or surrendered to another shelter. If the pet was lost, state how the pet was lost and when. If the pet was given away or surrendered to another shelter, state to whom the pet was given away or surrendered, when and why. *
With respect to each of your previous pets that has died, state the date of the pet's death, how old the pet was when he or she died, and the cause of the pet's death. *
Veterinarian Name/Practice: *
Veterinarian Address: *
Veterinarian Phone Number: *
Veterinarian Name/Practice:
Veterinarian Address:
Veterinarian Phone Number:
Veterinarian Name/Practice:
Veterinarian Address:
Veterinarian Phone Number:
What emergency hospital do you currently use or plan to use? *
Where will you keep your dog during the day? *
Where will you keep your dog during the night? *
Where will your dog sleep? *
If yes, how long do you intend to crate your dog each day? *
If no, please explain why not. *
If crating is not an option, do you have a dedicated room in your home that can be safely set up for a dog, especially at first, while no one else is at home (please explain, size, location, furniture, and other characteristics of the room)?
How many hours will your dog be alone each day? *
If no, please explain why not? *
If other, describe: *
What behaviors are you not willing to work on? (e.g., house-training, chewing, barking, digging) *
If yes, who has allergies and what allergies does he/she have? *
What would you do if a family member became allergic to the dog? *
What arrangements will you make for the care of the dog in case of an emergency, if you go on vacation, or if you become temporarily unable to care for the dog? *
In whose care do you intend to leave the dog if you become permanently unable to care for the dog? (Please provide name and number) *
Please list questions or concerns about which you would like more information:
Driver's License #: *
Expiration Date *
Reference 1 Name *
Reference 1 Phone Number(s) *
Reference 1 Relationship to You *
Reference 2 Name *
Reference 2 Phone Number(s) *
Reference 2 Relationship to You *