HSS Dog Adoption Application

Name of the dog you are applying for: Type a label (note that this application can apply to any)

Applicant:
Name(s):   First Name*   Last Name*  ,    First Name*   Last Name*
Phone(s):   Phone Number* ,Phone Number*
Physical Address:     Street Address*      City*   State*   Zip*
Email: Email*
Date of Birth:Type a label*

This dog would be an:*

Do you own or rent? If you rent, is it an apartment? (If you rent please be aware that you will be required to provide landlord permission that you are allowed to have a pet)*

Do you have a fenced-in yard? If so, what type of fence?*

Approximate size of fenced area?*

(If you don't have a fence, please type N/A)

How tall is the fence?*

(If you don't have a fence, please type N/A)

Is your fence complete all the way around with no gaps and in good condition, so that a dog would be safely contained?*

(If you don't have a fence, please type N/A)

If you live on a large property, please describe size, like in number of acres.*

(If you have a fence or don't live on a large property, please type N/A)

If you don't have a fence, how would the dog be contained from wandering off?*

(If you have a secure fence, please just type Fence)

Approximately how long would the dog be left alone? *

When the dog is outside, what type of shelter would be available?*

Where do you and your spouse/partner work?*

Do you and your spouse/partner go to school? If so, where?*

If you have children living with you, please list ages. *

(If you don't have children living with you, please type No Children)

Do you have other adults living with you?

What pets do you currently have or recently had? Please list the type of animal, its name, breed (if known), age, if they are/were spayed/neutered, and if they are still with you*

(If you have never had a pet before, please type N/A)

What happened to any pets you have had recently (within the past 5 years)?*

If you've never had a pet, please type N/A

Have you adopted from the Humane Society of Searcy before?   *
If so, what and when (approximately)?
If yes, where is that pet now?

For your current or past pets, which veterinary clinics have you used? (Please only list vets that you have used in the past, not one that you are planning to use but have not yet visited). Please list your most recent vet first, and then any others you have used below it*

(If you've never had a pet before, please type N/A

Please provide the owner's name(s) that the pet(s) would be listed under at the vet clinic(s)*

(If you haven't had a pet before, please type N/A)

Do you use heartworm prevention? * If so, what type?
Do you use flea/tick prevention? * If so, what type?

Where else have you purchased vetting meds (for vaccines or preventatives)?

Why are you a good adopter for this dog?*

Please type your name here. Note that this will act as an online electronic signature. *

By signing this application to adopt, I grant permission for the Humane Society of Searcy to follow up on the information I have provided above to confirm its accuracy. I also give permission to the Humane Society to confirm the veterinary treatment of my current or past pets. By signing this application to adopt, I commit to keeping the adopted animal fully vetted and up to date on vaccinations, flea and tick prevention, heartworm prevention and Rabies vaccine. I also state that I am financially able to do so. I understand that the Humane Society of Searcy has the right to refuse adoption to anyone.