Daisy's Place- Dog Adoption Application

Daisy's Place - Dog Adoption Application
Full Name*

First NameLast Name
Name of dog you are applying for:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?:*
Are you planning on moving within the next 6 months?*

YesNo
If yes, what are your plans for your pets if you move?
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Name of Employer:
Work Phone Number

Area CodePhone Number
Best time to reach you by phone*
E-mail*
Are you 18 years of age or older?*

YesNo
Birth Date*

MonthDayYear
Do you own your own home?*

YesNo
If no, name and phone # of landlord:
Type of Dwelling:*
Name and age of ALL occupants in household (including yourself):*
If no children, do you plan on having children or will children be visiting the household frequently?*

YesNo
What is your reason for wanting to adopt a dog?*

HousepetCompanionCompanion for petGiftGuard DogOther
If other, please explain:
How many total hours will your new pet be left alone during the day?*
How many total hours will your new dog be outside alone during the day?*
If adopting a puppy, where would the puppy be kept when alone?
Do you have a fenced yard?*

YesNo
If yes, which type of fence?*

WoodChain LinkSplit RailN/A
If yes, how tall is your fence?:*
Do you have locks and/or latches on all your gates?*

YesNoN/A
Will your adopted dog or do your current dogs be put on a tie out?*

YesNoNot sure
Are any members of your household allergic to animals?*

YesNo
If yes, please describe:
Who will have chief responsibility for the care of your new pet?*
Over the past 5 years, how many pets have you owned? (Include current pets)*
List each individually including breed, age, still living with you? (if not, why?)
Have you and your spouse (if applicable) ever owned a pet together?*

YesNoN/A
If yes, when?
Have you ever lost or given away a pet?*

YesNo
If you currently own a dog or cat, how does he/she react to new pets?
Are your present pets up-to-date on their annual vaccines?*

YesNoN/A
If no, please explain:
Are your present pets spayed or neutered?*

YesNoN/A
If no, please explain.
Were your previous pets spayed or neutered?*

YesNoN/A
If no, please explain.
How much are you financially prepared to spend for routine/emergency medical care, licensing, etc?*
What plans do you have for your new pet when you are on vacation?*
Can/Will you provide your dog with monthly heart worm/flea/tick prevention?*

YesNo
Who is your current or most recent veterinarian? Please provide their NAME and PHONE NUMBER:*
If your dog displays behavioral problems (such as jumping on people,excessive barking, potty accidents, etc.) how would you go about correcting the behavior?*

Contact a ProfessionalUse a bookPersonal KnowledgeOther
If other, please explain:
What type of solution would you be willing to try if housebreaking accidents continue after the first week (check all that apply)?*

Try crate trainingUse positive enforcementUse potty padsHave dog examined by vetUse a dog doorReturn dogNoneOther
If other, please explain:
Is your entire immediate family in agreement with the decision to bring a new pet into your home?*

YesNo
If anyone is NOT, please explain:
Are you prepared to commit to a pet for 15 - 20 years (average life span)?*

YesNo
Have you or any member of your household ever been charged with cruelty to animals or negligence in animal care?*

YesNo
If yes, please describe:
Have you ever adopted or tried to adopt a pet from us before? If yes, fill out info below.*

YesNo
Pet’s Information

Pet’s Name Dog?Adoption/Application Date
Where will your dog spend most of his/her time?*
If you selected outdoor, would your dog be supervised?

YesNo
Where will your dog eat?*
Where will your dog sleep?*
Please provide 2 personal references (only 1 can be a relative) that can testify to your responsibility and ability to care for your animals. This is required or your application cannot be approved.
Reference #1*
First and Last Name & Relationship to Self
Reference # 1 Phone Number*

Area CodePhone Number
Reference #2*
First and Last Name & Relationship to Self
Reference #2 Phone Number*

Area CodePhone Number
If there is anything else you think we should know, please note it here.
Adoption Fees:

Puppies up to 9 months- $900- with $200 rebate with proof of spay/neuter by 1 year of age.

9 months to adults- $850 including spay or neuter Spay/neuter.

The adoption fee includes; complete health records, vaccines to date of adoption and microchip.
Due to the volume of emails, phone calls, and messages Daisy's Place receives, it is not always possible to respond to every application. We do review every application. We will only be contacting applications that we feel are a good match for the dog you are applying for. Adoption will be to approved homes only, we reserve the right to deny adoption to anyone without providing a reason. Thank you for your understanding.
We may take approximately 2 to 3 business days for us to respond. Thank you so much for wanting to rescue with Daisy's Place.
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Daisy's Place - Dog Adoption Application

Please provide 2 personal references (only 1 can be a relative) that can testify to your responsibility and ability to care for your animals. This is required or your application cannot be approved.