Name

Age

Email Address

Pet ID / Name

Phone

Physical Address

Zip Code

Why do you wish to adopt this dog? (check all that apply) Why do you wish to adopt this dog? (check all that apply) Watchdog Hunting Breeding Companion for Myself Companion for Someone Else Companion for a Pet Gift for My Household Gift for Someone Else's Household Other

Name(s) of Intended Recipient(s)

Companion for Pet: What kind of pet?

Do you have experience with pets? Do you have experience with pets? I have pets now, and have had others before. I have had pets before, but I have none currently. I have pets now, but never before. No - I've never owned a pet.

Where Are Those Pets Now?

What Pets Do you Currently Have?

List the names and ages of all household members...

List the names and ages of all children that live in / visit the home...

Describe Your Residence (choose from dropdown) Describe Your Residence (choose from dropdown)HouseApartmentRV / Camper TrailerBoat HouseDuplex/Condo

Number of Years at Residence

Do you own or rent? Do you own or rent? Own Rent Lease None of these

Has your landlord given consent? Has your landlord given consent? Yes No We have not yet discussed

Landlord Name

Landlord Phone

Describe your yard (check all that apply) Describe your yard (check all that apply) No Yard Yard - Fully Fenced Yard - Partially Fenced Yard - Unfenced Dog Run / Pen Dog Cable Tieout Shade Pool / Water Source - Safety Gated Pool / Water Source - Open

Is there room for proper exercise and toilet needs? Is there room for proper exercise and toilet needs? Yes No Somewhat

What are your plans to meet their toilet / exercise needs?

Describe Cable Tieout

Size of Enclosure

Type of Fence

Are you willing to...

Teach young children about dog care/interaction? Teach young children about dog care/interaction? Yes No

Monitor young children around a dog? Monitor young children around a dog? Yes No

Get yearly wellness vet checkups? Get yearly wellness vet checkups? Yes No

Take them to a vet when sick or injured? Take them to a vet when sick or injured? Yes No

Welcome them as a new family member? Welcome them as a new family member? Yes No

Return them to EBC should they be unable to stay? Return them to EBC should they be unable to stay? Yes No

Maintain heartworm preventative? Maintain heartworm preventative? Yes No

Keep them on flea and tick prevention? Keep them on flea and tick prevention? Yes No

Have You Given Careful Consideration About...

Financial obligations? Financial obligations? Yes No

Requirements like special needs, time, patience, training, etc? Requirements like special needs, time, patience, training, etc? Yes No

An adopted pet's history and previous experiences? An adopted pet's history and previous experiences? Yes No

Why are you considering adoption?

My new dog shall live (describe in your words)...

Where will they be when you are home?

Where will they be when you are NOT home?

Where will they sleep at night?

Who will care for them while you're working?

Plans for Obedience Training?

What type of food will you provide for them?

Will you keep their tags on them at all times? Will you keep their tags on them at all times? Yes No

Will you give 4-6 weeks to adjust? Will you give 4-6 weeks to adjust? Yes No

Which Veterinarian do you / will you use?

What is the name of their clinic?

Phone number of this vet

Date of Last Visit

Name on Account

Do you provide your pet with heartworm preventive? Do you provide your pet with heartworm preventive? Yes No I don't have a dog / cat

What Brand of HeartWorm Medication do You Use?

Name of Groomer

Personal Reference #1 - Name

Personal Reference #1 - Address

Personal Reference #1 - Phone

Personal Reference #1 - Email

Personal Reference #2 - Name

Personal Reference #2 - Address

Personal Reference #2 - Phone

Personal Reference #2 - Email

Personal Reference #3 - Name

Personal Reference #3 - Address

Personal Reference #3 - Phone

Personal Reference #3 - Email

Are You Employed? Are You Employed? Yes No

Employer

Occupation

Work Address

Work Phone

Is Your Spouse Employed? Is Your Spouse Employed? Yes No I'm not married

Spouse Employer

Spouse Occupation

Spouse Work Address

Spouse Work Phone

Any comments or extra information you wish to share?