First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Cell Phone

Date of birth:*

Can you provide proof of identification*
Choose one: No Yes - I can provide you with my driver's licence # Yes- I can show identification prior to the adoption

Please provide driver's license # for proof of identification

Why do you want to adopt a dog? *

Describe what you are looking for in a dog:*

Please select the dog you wish to adopt. Please note that this list is difficult to keep up to date and dogs listed here may no longer be available:
Choose an animal: Athena (7 puppies) Blair Bonnie Bonny Bryan Caitlin (Iowa Litter of 3) Carson Cheens (Oak Helm Litter) Clyde Declan (Athena Puppy) Fiona (Athena Puppy) Gus Higgins Ivy (Emma Puppy) Ivy Maura (Athena Puppy) Kavanaugh (Athena Puppy) Kennedy (Athena Puppy) Marshall (Iowa Litter of 3) Martin (Iowa Litter of 3) Momoa "Moe" Murphy (Athena Puppy) Nacho Paddy (Athena Puppy) Patch Polar Taco Tallulah "Tully" Tiki Tobin "Toby" ZuZu

If the dog you wish to adopt is not listed above, please enter the dogs name:

Why are you interested in this particular dog and would you be open to others?*

Where do you live? *
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

How long have you lived at your current home?*

Do you own or rent your home?*
Choose one: Rent Own - I can not provide proof ownership Own - I can provide proof ownership

If you rent, please enter your landlord's name and phone number

If you decide to move in the future, what will you do with your companion dog? *

What will you do with your companion dog if you go on vacation or if there is an emergency requiring you to be gone?*

Do you have a fully fenced in yard? (This will be verified during the Home Visit)*
Choose one: Yard is not fenced in 4 foot chain link 6 foot chain link 6 foot privacy Invisible Other - please describe

If you chose "Other" please describe your fencing or how your dog will be let outside

Please describe how your dog will get exercise and mental enrichment:*

Where will your companion dog sleep?*

How many hours a day will your companion dog be alone consecutively?*

What method of correction will you use to correct the behavior of your companion dog?*

When are you available to adopt this dog and bring the dog home if you are approved (typically we do not hold dogs longer than a week, if longer than a week please explain why)?*

Employer (enter self, retired or unemployed if no employer):*

Occupation:*

Can you be contacted at work?*
Choose one: Yes No

Work Phone Number:

Do you come for lunch or have the ability for you or someone you know to let the dog out midday?*
Choose one: Yes No

Please list all the people in your home, their ages and their relationship to the applicant:*

Please list the employers of all the other adults in your home:

What behaviors will your household not tolerate long term in a dog (past an adjustment period)?*

Under what circumstances would you return or not keep your animal?*

Annual household income:*
Choose one: Under $15,000 $15,000 to $25,000 $25,000 to $35,000 $35,000 to $50,000 $50,000 to $75,000 $75,000 to $100,000 Over $100,000

Are all members of your household aware of your plans to adopt a dog?*
Choose one: Yes No

Are any members of your household allergic to animals?*
Choose one: Yes No

Who will be mainly responsible for the companion dog?*

Please list all animals currently in your home with their name, type (cat, dog, etc) breed, age, temperament):*

If you currently have dogs, where do they spend most of their time?

Please tell us about the pets that you have had in the past 5 years and where they are now:*

Have you ever surrendered or returned a pet for any reason? If so, please explain the circumstances. *

Are all the dogs and cats in your home spayed/neutered? If not please explain:

Are all the dogs and cats in your home current on vaccinations and prevention? If not please explain: (This will have to be verified with your veterinarian)

Please list the name and phone number of all veterinarians you have used and the names of the pets they saw:

If you know which veterinarian you plan to use for your companion dog, please list their name and phone number:

Name of Reference*

Phone #:*

Name of Reference*

Phone #:*

Name of Reference*

Phone #:*

What do you think your new dog will enjoy most about living with you?*

I hereby certify that all information supplied by me on this form is true. *
Choose one: Yes No

Please note that when you complete your application that you may have to scroll to the top to see your confirmation.