RCHS Application for Dog(s)

Name of Dog(s) You Wish to Adopt

Full Name *

First Name Last Name

Age

E-mail *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number - Home *

Area Code Phone Number

Phone Number - Cellular

Area Code Phone Number

Place of Employment *

Phone Number - Work

Area Code Phone Number

Do you live in a: *

Do you: *

Own Rent Live with Parents Other

If Renting: Please indicate landlord contact information

How long have you lived at your current address? *

Household Setting

Rural City

Describe the Activity Level in your Home *

Busy/Noisy Moderate Comings/Goings Quiet 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?

Yes No

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

Yes No

Please List any Pets you share or have shared a home with Currently or Within the past 10 years (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) *

Yes No

Veterinarian Name *

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number

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

Yes No

Where will the dog spend the day? *

Loose Indoors Crated Basement Fenced Yard Tied Out

Where will the dog spend the night? *

Loose Indoors Crated Basement Fenced Yard Tied Out

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

Yes No

If Yes, please explain

Are you willing to use a crate for a dog if recommended?

Yes No

Do you have a fenced yard? *

Yes No Partial

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? *

Today Tomorrow This Weekend Within the Week

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

Yes No

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

Yes No

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

Yes No

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.

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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?

PetFinder AdoptAPet Facebook RescueMe

Ritchie County Humane Society Adoption Application - DOG