First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Home Phone

Cell Phone

Spouse / Partner's name, if applicable:

Best way for us to contact you?

What type of home do you live in?

Do you own or rent your home?

If you rent, please provide your landlord's name and phone number. We call your landlord to verify that you are permitted to have a dog. Without permission from your landlord, we cannot let you adopt a dog.

List the ages of EVERY Person living in the home, including yourself:*

How long will the dog be left alone on a daily basis?*

How would you describe your family's lifestyle? Honesty helps us match you with the right dog.

Describe any pets currently in your home: age, temperament...

Are all of your current pets spayed/neutered?

If your pets are not fixed, please explain why not.

If you are interested in a specific dog, select a name from the drop down box. If you are interested in more than one dog, enter their names in the following question. If you are interested in dogs of a specific size, you may select Open Large, Medium, Small or Toy Dog from the drop down menu.
Choose an animal: Harley Molly Moo Open - Large Dog Over 60 lbs Open - Medium Dog 26-60 lbs Open - Small Dog 11-25 lbs Open - Toy Dog Under 10 lbs

Are you interested in any other dogs?

Describe the perfect dog for you and your family. Walking companion, a dog that can socialize with friend's dogs, a loyal companion, lap dog. etc.?

What size dog are you looking for?

What sex dog are you looking for?

What age dog are you looking for?

Is there a specific breed of dog you're looking for?

Is your yard fenced?

What type of fence do you have?

Who will take care of your dog in an emergency, or if you go away on vacation?*

Have you ever had to euthanize a dog for reasons other than their health?

If so, please explain the circumstances leading to this decision.

Have you ever re-homed, returned or surrendered an animal to a shelter or rescue? If so please explain the circumstances leading up to this decision.*

How would you handle unwanted / naughty behavior?*

How do you plan on exercising your dog?*

What is your training plan?*

Veterinarian Name and Phone Number:

List all pets cared for by your vet:

Reference 1: Name, Phone Number, Relationship*

Reference 2: Name, Phone Number, Relationship*

Reference 3: Name, Phone Number, Relationship*

By initialing this paragraph you agree that if the dog you adopt needs to be relinquished for any reason you will contact Homeward Bound CT and the Rescue.*