DOG ADOPTION QUESTIONNAIRE
Please take the time to fill out the following questionnaire.
We are committed to trying to make the best possible match between you, your family, and your new pet.

Name___________________________________________Age_____________

Address ________________________________County_____________________

City___________________ State ____Zip _______ Township ________________

Home phone ______________________  Alternate phone _________________________

Do you have an email address?  ______________________________________

Please provide directions to your home ___________________________________________________________________

_________________________________________________________________________________________________

Does this dog need to get along with other animals?  Yes     No

If yes, please list any pets that currently live in your house. If you need more space, use a blank sheet or the back of this page.

        Name                                                      Species                                                          Gender
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Who is your veterinarian?______________________________________________________

May we call your veterinarian for information about your pets' health history?      Yes        No

This dog needs to be good with children under 8 children over 8elderly people

Please list all other members of the household.  If you need more space, use a blank sheet or back of this page.
Name                                    Age             Relationship                                           Male/Female
1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
4. __________________________________________________________________________________
5. __________________________________________________________________________________

This pet will be primarily aninside dogoutside dog both

How many hours a day will this pet be home alone?4 hours or less/day8-10 hours/day12 hours/day

When I’m home I want my dog to be by my sideall of the timesome of the timelittle of the timenever

When I’m not at home, my dog will spend its timein the garagein a crate in the house in the yardloose in the houseconfined to one room in the house

I want a guard dogYesNo

I want my dog to be able to hunt/herd/work with meYesNo

I want my dog to be the type that is very enthusiastic in the way s/he shows affection to people.Not at allSomewhatVery

I want my dog to be playful.Not at allSomewhatVery

I want my dog to be laid back.Not at allSomewhatVery

I am comfortable doing some training with my dog to improve manners such as jumping, stealing food, and pulling on the leash.No trainingSome trainingA lot of training

I (or a family member) want to compete in Agility,Flyball or Obedience with our dogYesNo

I am interested in a dog with special needs (medical or behavioral)YesNo

Have you ever adopted from or surrendered a pet to a shelter?YesNo

Please list the names and telephone numbers of 3 personal references (not family members) who are familiar with you.

Name

Address

Phone

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Do you live in a House_____Apartment_____Mobile Home_____Other_____Do you Own_____Rent_____Landlord's name ______________________Phone _________

How long have you been at this address? ________________________________________

What will happen to this pet if you move?_______________________________________

Is there a fenced in yard? _________If yes, what kind of fence/how high?____________________

Do you understand that PA law requires that all dogs over the age of 12 weeks be vaccinated against rabies, that all dogs over 3 months must be licensed, and that it is against the law to allow your dog to run at large?________

Are you financially prepared to give your dog the medical care it requires (vaccinations, deworming, regular vet visits)?________

Our shelter likes to keep in touch with our adopters to be sure that the pet is working out as expected, and to be able to help with any problems that may develop in the future.Would you prefer to be contacted by phone __________or email _____________?

If by phone please let us know the best time to call you.____________________________

I certify that the above information is accurate, and I give my permission for Dessin to contact any of the names listed on this application. I understand that all adoptions must be paid for in cash or with a credit card.  I also understand that Dessin makes no guarantee as to the health or temperament of any of the pets for adoption.

Signature_____________________________________________  Date_____________________

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