Adoption Application

How did you hear about Southern Dog Mission

Name of dog that you wish to Adopt:

Is there a second option:

Full Name*

First NameLast Name

Age

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number - Home

Area CodePhone Number

Do you live in a:

Do you:

OwnRentLive with ParentsOther

If Renting: Please indicate landlord contact information AND Is there a pet policy?*

Do you have a yard?

YesNo

Is your yard fenced in?

YesNoPartially

Have you ever surrendered a pet you own to any animal shelter including a "low" or "no kill" shelter?

YesNo

Please List all People Living in the Household (Include Name, Relationship, Gender and Age)*

How many hours per day would the pet be alone? Where would the pet be left when alone?*

Will you crate your pet?

YesNo

If you have to leave town, emergently or planned, where would your pet stay?*

How would you deal with behavioral issues such as barking, chewing, destructive behavior, bathroom accidents indoors, unruly leash behaviors in your pet?*

Are all members of your Family agreeable to adopting a Dog?

YesNo

Please List any Pets you have Living (Please include Name, Breed, Age, Sex and are they fixed?, UTD Vaccines, Heartworm)*

We cannot guarantee a dog to be housebroken, are you equipped to train with love and patience?

YesNo

Have you had any experience with with an emotionally or physically neglected or abused dog?

YesNo

If Yes please explain

Please list 3 personal references with names, addresses, phone numbers and how related. We prefer it not to be all relatives. Are you ok with this?

YesNo

Vet Reference: Full Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Reference #1: Full Name*

First NameLast Name

Relation to applicant(s):

E-mail

Reference #2: Full Name*

First NameLast Name

Relation to applicant(s):

E-mail

Phone Number

Area CodePhone Number

Reference #3: Full Name

First NameLast Name

Relation to applicant(s):

E-mail

Phone Number

Area CodePhone Number

By sending this electronically, I acknowledge that I have completely read this questionnaire and comprehend it fully.

I understand that applying does not ensure approval and that untruthful answers or failure to comply with the requirements of this application can result in the forfeiture of any SOUTHERN DOG MISSION animal adopted by me.

I certify that the above information is correct, and I understand that the information will be verified.

I understand that by submitting this form electronically, I agree to release and covenant to hold harmless SOUTHERN DOG MISSION and it's members from any claims, damages, costs, or actions incurred because of the care or actions of the adopted dog.

I accept full responsibility for the dog(s) actions at all times, and release SOUTHERN DOG MISSION from any liabilities or damages that may be incurred because of adopting such dog(s).

I agree to have SOUTHERN DOG MISSION complete reference call checks and conduct a home visit inspection to be able to approve my adoption application.

Date

MonthDayYear

Your name*

E-mail