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1
Dog you are interested in:
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Small dog, any breed, preferably terrier mix,
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2
First and Last Name
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Colleen DeLeeuw
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3
Address, City, State, Zip
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154 Andover Sparta Rd, Newton, NJ, 07860
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4
Primary Phone Number
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973-670-9907
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5
Secondary Phone Number
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6
Email Address
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Colleenmjr3@gmail.com
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7
Type of Residence
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Home, in lake community
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8
Do you own or rent
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own
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9
How long have you lived here?
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5 years
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10
Would you be able to provide landlords proof of animal acceptance at premises? Lease / Letter from Landlord.
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yes, own home
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11
If you are renting, please provide you landlord's name and phone number
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Colleen DeLeeuw 973-670-9907
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12
Do you have a fully fenced backyard?
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no
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13
Is this the first time you have owned a dog as an adult?
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no
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14
Please provide your veterinarian's name and phone number
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Dr. Linda Gr
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15
Please list all animals that currently live in your home or that you have owned in the last three years. Name, breed, age, and sex. If you do not own them anymore, please explain why.
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Currently none, cat passed two years ago (20 yrs old), Golden Retriever passed four years ago (16 years old)
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16
Please list all persons living in the home / relationship / age
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Myself 59 years, husband 62 yrs
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17
Are all the animals in your household spayed or neutered?
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No animals
Yes
No
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18
Does anyone in your house have allergies to animals?
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no
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19
Does anyone in the home have a medical condition that will stop them from providing care to the animal?
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no
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20
Please describe what kind of dog you are looking for (long or short hair, size, weight, male/female, age)
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Med hair, scruffy, mutt, small, male or female, 6 mos - 5 yrs
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21
Please select all the qualities that you are looking for in a dog
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easy on leash, lap dog, calm, quiet, enjoys car rides, good with other dogs
Easy on a leash
Lap dog
Confident
Playful
Enjoys car rides
Active
Protective
Rough houser
Good with other dogs
Independent
Gentle
Energetic
Good with cats
Calm
Dependent
Quiet
Enjoys hiking, jogging, running
Good with children
Adult dog that is settled
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22
Do you plan to crop the ears or tail or debark your new dog?
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no
Yes
No
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23
What are some training needs that you do not wish to encounter?
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housebreaker
Housebreaking
Escaping
Digging
Chewing
Excessive barking
Protective
Leash pulling
Jumping
Stubborn
Food aggression
Toy aggression
Shy/fearful
Plays too rough
Needs a lot of attention
Other
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24
There are some behaviors that require patience, formal training, or prior dog experience. If your new dog does display any of these behaviors, how will you go about teaching him/her?
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Contact trainer
Contact a professional
Use a book
Google
Personal knowledge
Other
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25
How would you describe your household?
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quiet, small
very active
lots of kids visit
some activity
frequent adult visitors
quiet
Other
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26
When you are home, where will your new dog be?
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loose in home, within outside area, bringing on walks
Loose in the home
Crate in the home
Loose outside
Tied up outside
Outside kennel/pen
Within fenced yard
Garage
Doghouse in yard
Basement
Other
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27
When you are NOT home, where will your new dog be?
*
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home, crate if needed
Loose in the home
Crate in the home
Loose outside
Tied up outside
Outside kennel/pen
Within fenced yard
Garage
Doghouse in yard
Basement
Confined to a room
Runner in yard
Doggie day care
Other
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28
All dogs require exercise. How will your new dog get adequate exercise?
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regular walks
Run in yard
Outdoor kennel/pen
Fenced yard
Daily leash walks
Loose outside
Off leash dog park
Hiking/jogging
Mid-day dog walker
Doggie day care
Other
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29
Do you have a steady stream of income?
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yes
Yes
No
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30
If you are employed, please indicate where you work, and or spouse work. provide work phone numbers.
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Hudson Farms, Andover, NJ
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31
Provide at least one work reference for each working person in the household.
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Dr. Alex Ciuffitelli, VMD 908-914-7630
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32
There are additional expenses for pets for routine care and possible unexpected medical costs. Are you prepared to be financially responsible for you new pet?
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yes
Yes
No
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33
It may take weeks for the new dog to adjust to a different environment. It may even require keeping the animals separate to introduce them properly. Are you prepared to handle this?
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yes
Yes
No
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34
In a new environment it can be hard to determine if an animal is housebroken. Will you be able to tolerate accidents and train the pet?
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yes
Yes
No
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35
Are all family members in agreement about adopting a dog?
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yes
Yes
No
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36
Have you or any member of your household been subject to legal action for cruelty to, neglect of, or abandonment of any animal?
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no
Yes
No
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37
Home checks are required prior to adoption. Will you allow us to complete a home check?
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yes
Yes
No
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38
I understand that purposeful falsification of the information contained in this form will result in automatic denial of an adoption, or subsequent confiscation of already adopted pet (s). I certify that the information I have provided herein is accurate and I authorize STRAY TO HOME ANIMAL RESCUE to investigate all statements made on this questionnaire. I understand that Stray to Home Animal Rescue, makes no representation or guarantee about any animal's temperament, behavior, health or any combination thereof. STHAR is not held liable for any future injury or damage, which may be caused by any adopted animal, nor is STHAR responsible for any illness or medical malady, which may befall the animal subsequent to adoption. STHAR reserves the right, at our sole discretion, to refuse any applicant for any reason.
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i understand
I understand
I do not understand
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39
Are there any topics that you would like to discuss with our adoption coordinator?
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not currently
no
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40
Tags
Todo
In Progress
Done
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STRAY TO HOME Dog Adoption Application
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