Canine Wait List

Canine Wait List
This form is not an application. You will need to fill one out later if we have a dog that is suited to your needs.
What type of dog are you interested in? (Species, name)*
Reason you want a dog

ESDService AnimalPet
Please Provide More Information on why you want a dog through our organization
Your name*
First & Last Name
Your Address*

Street Address

Street Address Line 2

CityState

Zip Code
Your Email*
Your Phone Number*

Area CodePhone Number
Phone Type*

CellHomeWork
Names and ages of all permanent residents of your home (adults/children)*
Please list any pets currently living in your home, and if they are vaccinated and altered.
How long will the dog be left alone during the day? Describle your work schedule and employment
Have your current or previous dogs been on heartworm prevention? This will be verified through vet records at a later time*
Are you planning to move in the near future?*

YesNo
If moving soon, to what city/state?
When will you be ready to adopt this animal?*

TodayThis weekendWithin a weekWithin a monthNot ready yet, just researching
Is anyone in your home allergic to the animal you're planning to adopt?*

YesNoYes, but it is tolerable for them and they are OK with it.
Are you familiar with the breed?*

YesNo
You live in a:*

Single Family HomeDuplex/TwinCondo/TownhomeTrailerApartment
Do you rent or own this property?*

RentOwn
If you rent, you must give the person you are adopting from a written letter from your landlord or a copy of the section of your lease stating that you are allowed to have this type of animal and showing any limitations.

If you live in a condo or townhome, you must show us written proof that you are allowed to have this type of animal there and show any restrictions.
Do you have a yard?*

Yard, fenced with a vertical fenceYard, fenced with invisible fencingYard, no fenceNo yard (apartment/condo/townhome)
Have you discussed this adoption with all members of your household?*

YesNoYes, adults have discussed. Kids don't know yet.
Do you have any additional comments, questions or concerns?*
By checking the box below, you understand that a background check will be conducted.

I understand the above, and have tried to the best of my knowledge to make sure all information is correct.
Signature*
Signature date*
Thank you for taking the time to submit this form. We do receive many requests. If we have a suitable dog we will be in contact.
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