RCHS Application for Dog(s)

Ritchie County Humane Society Adoption Application - DOG
Name of Dog(s) You Wish to Adopt
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
Phone Number - Cellular

Area CodePhone Number
Place of Employment*
Phone Number - Work

Area CodePhone Number
Do you live in a:*
Do you:*

OwnRentLive with ParentsOther
If Renting: Please indicate landlord contact information
How long have you lived at your current address?*
Household Setting

RuralCity
Describe the Activity Level in your Home*

Busy/NoisyModerate Comings/GoingsQuiet with Occasional Guests
Please List all People Living in the Household (Include Name, Relationship, Gender and Age)*
Does Anyone in your Household have Allergies to Animals?

YesNo
Are all members of your family agreeable to Adopting a Dog?*

YesNo
Please List any Pets you share or have shared a home with Currently or Within the past 10 years, this includes outside pets as well (Please include Name, Breed, Age, Spayed/Neutered, Sex, Living/Deceased)*
Do we have permission to call your veterinarian for a reference check? (Please authorize vet to speak with us)*

YesNo
Veterinarian Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

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

YesNo
Where will the dog spend the day?*

Loose IndoorsCratedBasementFenced YardTied OutOther
Where will the dog spend the night?*

Loose IndoorsCratedBasementFenced YardTied OutOther
Have you had any experience with an emotionally or physically neglected or abused dog?

YesNo
If Yes, please explain
Are you willing to use a crate for a dog if recommended?

YesNo
Do you have a fenced yard?*

YesNoPartial
If fenced, please give details on height, material, # of gates, are gates locked or lockable?
How many hours in a day would the dog be left alone?*
What are you plans to exercise your dog? Please list any parks near by or trails, how many walks a day, approximate length, activities such as agility*
What drew your attention to this particular dog?
When will you be ready to adopt this dog?*

TodayTomorrowThis WeekendWithin the WeekOther
Do you understand that we require this dog to be spayed/neuter within 30 days in accordance to WV law?*

YesNo
Do you agree to license this dog and give it regular health care?*

YesNo
Do you agree to contact us if you can no longer keep the dog?*

YesNo
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.

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

MonthDayYearHourMinutesAM/PM Option
Your name*
Co-Applicant name (if applicable)
Please help us determine where our marketing is working best. Where did you see this dog's listing?

PetFinderAdoptAPetFacebookRescueMeOther
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Ritchie County Humane Society Adoption Application - DOG