Your full name:

Your email address: (e.g.: you@aol.com)

Your home phone number (with area code):

Your cell phone number (with area code):

Your work phone number (with area code):

Your employer:

Your occupation:

Address:

City:      State:    Zip Code:

Please list names and occupations of other adults in the household:

Do you have children? If so please list name and age of each:

Name of a personal reference:
Phone number of personal reference:
Years acquainted:
Email address of personal reference:

Do you have pets currently? If so please list breed, sex and age of each:

Are all of your current pets spayed or neutered?:
Yes, all pets currently are spayed or neutered.
No, all pets are not currently spayed or neutered.

If your current pets are not spayed or neutered, why?

Why do you want to adopt a dog?:

Describe the dog you are looking for (age, sex, color, etc):

Do you have a particular dog in mind?:

What are your plans for this dog?:
This dog will be a pet.
For guarding my home or office.
For hunting.
I would like a dog for breeding.
Other. Please describe:

Have you ever had to give up a dog?:
Yes, I have given up a dog.
No, I have never given up a dog.

If you have given up a dog before, why?

Who will feed, exercise and train the dog?:

How do you plan to train the dog?:

Where will the dog sleep at night?:

How many hours will the dog be alone each day?:

Where will the dog be kept during the day?:

Who will take care of the dog in your absence (vacations, emergencies)?:

Are you willing to attend an obedience class with the dog you adopt?:
Yes, I will attend an obedience class.
No, I will not attend an obedience class.

Do you currently have a veterinarian?
Yes, I do have a veterinarian.
No, I do not have a veterinarian.

If you do have a veterinarian please list their name, city and phone with area code:

If you do not have a veterinarian, how do you plan to find one?:

Describe your current accommodations:
I live in an apartment.
I live in a condominium.
I live in a single family home.
I live on acreage.
I live in a mobile home.
Other. Please describe:

How long have you lived at this address?:

Who is your homeowners/renters insurance carrier?:

Are you aware of any breed specific exclusions on your plan?:
Yes
No

Describe your yard:

Is your yard fenced?:
My yard is fenced.
My yard is not fenced.
If your yard is fenced, how tall is it?:

If you do not have a fence, how will exercise/toilet be handled?

Do you own or rent?
I own my home.
I rent my home.

If you rent, do you have permission to have a dog?:
Yes, I do have permission to have a dog.
No, I do not have permission to have a dog.

Landlord's name:

Landlord's phone:

May we contact your landlord to verify that you may have a dog on your property?:
Yes, you may contact my landlord to verify my permission to have a dog.
No, you may not contact my landlord to verify my permission to have a dog.

May we visit your home before and after you adopt a dog?:
Yes, you can visit my home before and after adoption.
No, you cannot visit my home before and after adoption.

Is anyone in your home allergic to animals?:
Yes, someone in the household is allergic to animals.
No, no one in the household is allergic to animals.

How long do you plan to keep this dog?:

How much money would you consider to be a major medical expense?:

Is your entire household supportive of this adoption?:
Yes, the entire household supports this adoption.
No, the entire household does not support this adoption.

If the entire household does not support this adoption please explain why:

How did you find out about us?:
I found you on a web search engine.
I found you on a website link.
I found you in a newspaper ad.
I found you in a magazine ad.
I found you by word of mouth.
Other. Please describe:

Any additional comments or questions:

By clicking on “Submit Application” I am agreeing that the above information is true and correct and understand that this information will be included with my adoption contract and if found to be untrue at any time (even following adoption) the dog or cat may be reclaimed at no expense to Mercer County Humane Society. Further, by applying for the adoption of a dog or cat I hereby give permission to my Veterinarian, my personal reference and landlord (if applicable) to disclose information to Mercer County Humane Society.

I understand that incomplete applications will not be processed.