First Name*
Last Name*
Address*
City*
State/Province*
Zip/Postal Code* -
Email*
Home Phone*
Work Phone x
Cell Phone
Alt Email
Please confirm your age.
Please provide a link to your Facebook page:
Employer's Name (if employed)
Employer's Phone Number
Spouse/Partner’s Employer’s Name (if applicable)
Spouse/Partner’s Employer’s Phone Number (if applicable)
What is your current housing situation?*
Type of home*
Length of time you have lived at this address*
If your home is an apartment or condo, please provide landlord's/condo association's name
May we contact your landlord/housing association to confirm pet policies at your place of residence?
Please list the adults that live in your home, their age, and their relationship to you:*
Please list the children that live in your home, their age, and their relationship to you:*
Do any household members have allergies to animals?*
If yes, please describe allergy
Are all members of your household in agreement with this adoption?*
Who will be the primary caretaker of your adopted pet?*
Who will have financial responsibility for this pet?*
Where do you plan to keep this dog when you are home?*
Where do you plan to keep this dog when you are not home?*
How many hours per day will your adopted dog be alone?*
Is your yard fenced* Choose one: No Yard Unfenced Yard Fenced Yard
If you have a fenced in yard, what type of fence is it? Choose one: Privacy Chain Link Invisible
What is the height of the fence
May a member of GDHS visit your home by appointment?*
Please list the name and phone number for two references*
Veterinarian's Name*
Veterinarian's Phone Number*
Dog I am interested in* Choose an animal: Dog Waiting List Gus Kiki Patches Rooney Twiggy Zuzu
Why would you like to adopt this/a dog?*
What qualities and characteristics are you looking for in a dog companion?*
What pets are currently in your household? Please list type of animal, gender, age, and breed of each:*
If you have had pets in your household in the past 5 years that are no longer with you, please list type of animal, gender, age, and why they are no longer with you.*
Have you ever had to rehome or surrender a pet? If so, why?*
Have you ever had a pet euthanized? If so, why?*
What type of exercise are you planning on giving your dog?*
Describe how you will train the pet*
Do you have any specific questions or concerns about adopting this dog?
Would you be interested in fostering animals for GDHS? If so, dogs and/or cats?
How did you hear about the Greater Derry Humane Society and/or the dog you would like to adopt?*
Would you like to receive our electronic newsletter?
Please read and sign below
Many factors determine which applicant will be matched with a particular pet. If you are not approved to adopt a particular, it does not mean that you are not considered a good pet owner or that your home is not acceptable. Our goal is to place all animals into homes that will best suit their individual needs. Please ask for clarification if you have any questions.
Please not call-if after you have received the email confirmation. We have received your application. We are all volunteers and there is no physical office or shelter. We communicate primarily through email.
Thank you!
By typing my first and last name below, I certify that the information I have given is true and I recognize that any misrepresentation may result in rejection of my application. This serves as my legal signature, and authorizes The Greater Derry Humane Society to verify all information provided.*
Today's Date (mm/dd/yyyy)*