Please indicate where you live: apartment house condo/townhouse trailer/mobilehome
Do you... rent home own home
If you rent, do you have the landlord's permission to own a dog? Yes No
      What is the apartment complex name?
      What is the landlord's phone number?
      How much is the pet deposit? $

How many times have you moved in the past 5 years? times
If you move, will your pet go with you? Yes No
Would you ever consider moving somewhere that doesn't allow your pets? Yes No
Do you foresee any major changes in your life in the next 15 years (average lifespan of a dog) such as marriage, childbirth, health problems due to age, going away to college? Yes No
If yes, please explain:
Do you or anyone in your household currently have any serious health problems? Yes No
If so, please describe:
Can you provide a permanent home for this dog for 10-15 years? Yes No

What procedures will you use for housebreaking? crate training newspapper rubbing nose swatting with newspapper outside only; Other, please describe

Do you have a fully fenced yard with no fence gaps? Yes No
If yes, how high and what kind?
If no, would you consider fencing all or part of it as a condition of adopting a dog? Yes No

Number of adults in household?
Relationship(s):   spouse   roommate(s)   life partner   other - please specify:
Does anyone in the household smoke? Yes No
Will this dog be a surprise for any family members? Yes No
If yes, who?
Do any family members have allergies? Yes No
Do any children live in the house? Yes No
If so, what are their gender/ages?

Number, type and age of pets currently in household?

Do any of your current or did any of your past pets live primarily outdoors? Yes No
If yes, please describe pet:
Were all previous pets spayed/neutered? Yes No
Are all current pets spayed/neutered? Yes No

Do you know what heartworm disease is and how to prevent it? Yes No
Is your current dog or was your previous dog on heartworm prevention medication? Yes No
If yes, how often did you give the heartworm medication? What brand did you use?
What is your veterinarian's name and phone number?
What do you expect annual pet care (vet care, medication, heartworm preventative, etc.) to cost yearly?   $

How many dogs have you owned in the past?
If any, please describe what happened to each of them (put to sleep, run over, died of old age, sold, given away, ran away, etc.)

Who will be responsible for the daily care and training of your new dog?

How do you plan to prevent fleas and ticks?
Are you aware of Frontline or Advantage? Yes No

How many hours will the dog be home alone on a typical day?

Where does your current dog stay when home alone during the day? outside in fenced area outside in dog pen outside on chain or tie-out inside in basement in the garage inside free run of house inside in one room of house inside in crate ; other, please describe:
Where will your new dog stay when home alone during the day? outside in fenced area outside in dog pen outside on chain or tie-out inside in basement in the garage inside free run of house inside in one room of house inside in crate ; other, please describe:

Where do current pets sleep at night? dog house in fenced area dog house in dog pen dog house near tie-out inside in basement in the garage inside free run of house inside in one room of house inside in crate in my bed ; other, please describe:
Where will the new dog sleep at night? dog house in fenced area dog house in dog pen dog house near tie-out inside in basement in the garage inside free run of house inside in one room of house inside in crate in my bed ; other, please describe:

What percentage of time will the dog spend inside the house? %
Will your new pet be allowed on the furniture? Yes No

Have you ever had a serious behavior problem with a previous dog? Yes No
If so, please describe:

Do you have a doggie door? Yes No
If not, and if it would work better, would you consider installing a doggie door? Yes No

Have you always kept an ID tag (other than a rabies tag) bearing your phone number on your pets? Yes No
Are you willing to keep a collar and ID tag on all of your pets including a new dog at all times? Yes No

Under what circumstances do you think it is OK to leave a dog outside alone and unsupervised in an unfenced area?   in a quiet subdivision   on a lot of acreage   in a rural area   when I know they are trained to come back   none

What circumstances, in your mind, justify giving a dog up?   moving   new baby   not getting along with other pets   divorce   getting out of fence   behavioral problems   children lost interest   if it gets too big   too time consuming   shedding   allergies   housebreaking problems   medical problems   aggressive behavior   other - please explain:
Have you ever given a dog up or had a dog for a brief period of time and it didn't work out? Yes No
If so, please explain the circumstances and what happened to it:

Have you ever looked at or applied for a pet with another rescue group? Yes No
If so, how long ago? Did you adopt? Please explain:

If you are unable to keep your dog for any reason at any time will you return the dog to us? Yes No

If you date or marry someone who does not like or want your pets, what would you do?

If your pet later develops a medical problem that becomes expensive, what would you do?   Find another home for him   Pay whatever it takes   Have him put to sleep   Give him to a rescue group or shelter   other - please explain:

If your pet develops a frequent urination problem at the age of 12 and can't hold it when left alone, what would you do?   Have him put to sleep since he is older   Babygate him in where flooring is not carpeted   Give him to a rescue group or shelter   Put in a doggie door   other - please explain:

If you are considering a long-haired breed, how often would the dog be groomed?
Would he get haircuts? Yes No Would you do it yourself? Yes No Have a groomer do it? Yes No

What type of food will you feed?   something from the grocery store   premium food from a pet supply store  
Brand name:

Has a dog or puppy died on your premises in the last 6 months of distemper, parvo or unknown causes? Yes No

Please list the names, addresses and phone numbers of 2 personal references:

How did you hear about Southern Hope?   Southern Hope website   Petfinder website   Petshelter website   newspaper   word of mouth   radio   at an adoption day   other - please specify: