MomsVA Animal Adoption Application
Thank you for your interest in adopting a rescued canine orphan. Please give yourself ample time to complete this application. Our goal is to make lifelong matches for dogs and people. Because MomsVA is run solely by volunteers, please allow us time to review your completed application. We will contact you as soon as we can. This form is confidential: This form is designed to help you find the dog or puppy most compatible with your lifestyle. MomsVA will maintain the information provided below as confidential and will not share your information with any outside individuals or organizations without your express consent. Completion of this application does not obligate you in any way or guarantee the adoption of a MomsVA dog or puppy. MomsVA reserves the right to approve or deny any application for any reason and the right not to disclose the reason. All MomsVA adult dogs and puppies are spay/neutered prior to adoption. It is possible that an approved adopter may experience a short waiting period (for spay/neuter to occur) between being approved and being able to take the dog or puppy home. In the event this occurs, we thank you for your patience. Please complete all the following questions completely to the best of your knowledge. Be sure to complete questions with a red *. These items are required and you will not be able top continue the application if any of them are left blank.
Applicant Information
If applicable, name(s) of the dog(s) on our website that interest you:
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Your Name
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Breed(s) of dogs that interest you
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WORK Phone Number
HOME Phone Number
CELL Phone Number
Best Contact Number
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WORK Phone
HOME Phone
CELL Phone
Email Address
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Your Complete Address (STREET ADDRESS, CITY, STATE, ZIP)
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Please answer the below
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Rows
Yes
No
Are you over 18 years old?
Are you over 70 years old?
Your Occupation
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Your Employer's Name and Address
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Household Information
Names of other adults in your household
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Other Adult's Occupations (include employer name(s) and addresses)
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Names & Ages of children in the household
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Are you aware of your county's or city's number of allowed pets?
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Yes
No
Who will be the primary caregiver for your new dog/puppy?
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Is this the first dog for you and your family?
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Yes, the first that I will be responsible for financially
Yes, but I grew up with dogs
No
Are all the adults in your household aware that you are adopting a dog or puppy?
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Yes
No
Planning as a surprise/Gift
Does any member of your household have pet allergies?
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Yes
No
Not Sure
Who is financially responsible for your current pets?
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Current Pets?
1) Other pet in the House (Name, Breed, Age)
Gender
Male
Female
Please answer the below on this pet.
Rows
Yes
No
Unsure
Spayed/Neutered?
Current on Vaccinations?
Name, Address and Phone Number of current veterinarian
Names of pets with records at this vet
Owner name on the records at this vet
If your current vet has seen your pet for less than 1 year, please provide the name & number of your previous vet below.
2) Other pet in the House (Name, Breed, Age)
Gender
Male
Female
Please answer the below on this pet.
Rows
Yes
No
Unsure
Spayed/Neutered?
Current on Vaccinations?
Name, Address and Phone Number of current veterinarian
Name, address and phone number
Names of pets with records at this vet
Owner name of the records at this vet
If your current vet has seen your pet for less than 1 year, please provide the name & number of your previous vet below.
3) If there are other pets in the household, please use the space below to provide the same information for those pets.
Is there any additional information about your current pets that you would like us to know?
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Other Previous Pets?
1) Pet Name
Breed
Spayed/Neutered?
Yes
No
Years owned
Where is this pet now? If the dog has passed, please provide the approximate date when he/she passed.
Name, Address and Phone Number of veterinarian for this pet
Owner name for the records at this vet
3) If you have had other previous pets, please use the space below to provide the same information for those pets.
Is there any additional information about your prior pets that you would like us to know?
Please answer the below.
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Rows
Yes
No
Has anyone in your household EVER given a pet away?
Has anyone in your household EVER released a pet to an animal shelter or rescue?
Has anyone in your household EVER sold a pet?
If YES to any of the last 3 questions, what were the circumstances?
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Lifestyle Information
What temperament and activity level are you seeking in a dog?
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Athletic/High Energy
Affectionate
Mellow
Quiet
Lap Dog
Are you adopting a dog for any of the following reasons?
Hunting dog
Guard Dog/Protect Property
What do you hope a new dog/puppy will add to your life?
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Do you own or rent?
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Own
Rent
If renting, please provide your LANDLORD'S NAME and contact phone number:
How many hours each day will the dog or puppy be left alone?
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Where will the puppy/dog be kept when alone? (select all that apply)
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Indoors
Outdoors
In a dog crate
If indoors and not crated, in what room will the dog/puppy be kept?
What type of housing do you live in (single family house, apartment, townhouse, etc.)
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Please answer the below
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Rows
Yes
No
Do you have a completely fenced yard?
Is there a gate?
Do you have a pool?
Is there a fence around the pool?
If FENCED, what is its height (3 ft, 4 ft, 6 ft, etc.) and type? (picket, privacy, split rail, post-and-rail, chain link,etc.)
Where will the dog/puppy be kept during the day when you are home?
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What type of exercise will you give the dog/puppy?
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Realistically, how many hours per day do you have to exercise with and/or play with your dog?
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Less than 1 hour
1-2 hours
2-3 hours
More than 3 hours a day
Where will the dog/puppy sleep at night?
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How often will the dog/puppy get exercise?
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Are there times when the dog will be tied outside?
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Yes
No
If YES, when and for how long on average?
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Training & Development
Please answer the below
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Rows
Yes
No
Unsure
Do you know what causes heartworms?
Do you agree to keep your dog/puppy on heartworm preventative all year round?
Do you plan on attending obedience classes with your new dog/puppy?
What methods will you use to train your new dog/puppy?
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If your new dog/puppy has an accident in the house, how will you correct him/her?
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How long do you think housebreaking will take?
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When you go on vacation, who will care for your dog/puppy?
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If you move, what will you do with your dog/puppy?
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How much are you willing to spend annually on medical bills for the dog/puppy?
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What provisions will you make for the dog/puppy should you become unable to care for it?
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Please answer the below
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Rows
Yes
No
Unsure
Are you ready to take responsibility for this dog/puppy for the next 10-15 years?
Are you willing to have a MomsVA representative visit where the dog/puppy will be living
Have you ever incurred extraordinary or unexpected vet expenses?
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Yes
No
If yes, please explain
Have you previously applied to adopt a dog, puppy, cat or kitten from a rescue group or shelter
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Yes
No
If yes, when and what rescue group or shelter? And what was the result of the application?
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References
Please provide TWO personal references of someone not living in your home.
Please provide name, phone number and relationship to you of your first reference
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Please provide name, phone number and relationship to you of your second reference
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Is there anything else that you feel we should know?
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AUTHORIZATION/RELEASE: By signing (spelling out your full name on this form) below and submitting this form, I certify that all information given in this application is true and correct, to the best of my/our knowledge. By submitting this form, I hereby further grant consent to MomsVA and its agents to seek information about me from all named and unnamed sources within this application, including but not limited to veterinarians, rental agents, and personal references, regarding this application. Providing false information or refusing to sign below will result in the rejection of the application or the nullification of the adoption agreement. MomsVA reserves the right to approve or deny any application for any reason and the right not to disclose that reason. Printing your name represents your official signature in the space(s) below.
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Signature/Name of Applicant
Signature/Name of second applicant if applicable
Submit
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