Owner's Details
Name of owner
First Name
Last Name
First Name
Last Name
Owner's Address
Street Address
Street Address Line 2
City
State
Postcode
Phone Number
-
Area Code
Phone Number
Primary Mobile
Used for normal communication
Mobile
If primary mob unavailable
Primary Email
example@example.com
Secondary Email
example@example.com
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Dog Details
Copies of the vet paper work will be given to the adoptee (new owner) after adoption. You may like to blank out personal information e.g. your address. Please do not edit any details about your dog(s).
Number of dogs and homes
*
One dog that needs a new home
Two dogs that need to be re-homed together (one home)
Two dogs that need to be re-homed into two homes (two separate homes)
Other
Administration Fee Payable
Name of dog
*
Name of dog #2
*
Sex
Male
Female
Sex #2
Male
Female
Date of Birth
*
Date of Birth #2
*
Breed
*
Breed #2
*
Kgs
*
Kgs #2
*
Micro chip
*
Yes
No
Micro chip #2
*
Yes
No
15 digit Micro chip number
15 digit Micro chip number #2
Micro chip registry
Micro chip registry #2
Micro chip Payment due
Micro chip Payment due #2
Sterilised?
Yes
No
Sterilised #2 ?
Yes
No
Upload Sterilisation Certificate
Must be signed by vet
Upload Sterilisation Certificate #2
Must be signed by vet
Sterilisation payment due
Sterilisation payment due #2
Will vaccination injection expire within 3 months of adoption?
No
Yes
Will vaccination injection expiry within 3 months of adoption #2 ?
No
Yes
Upload current vaccination certificate
Must be signed by vet
Upload current vaccination certificate #2
Must be signed by vet
Vaccination Payment due
Vaccination Payment due #2
Intestinal worm prevention
None
Oral every 3 months
Oral each month
Other
Intestinal worm prevention #2
None
Oral every 3 months
Oral each month
Other
Heart worm prevention
None
Annual Injection
Oral
Dab-on
Other
Heart worm prevention #2
None
Annual Injection
Oral
Dab-on
Other
Upload heart worm injection card
Upload heart worm injection card #2
Flea prevention
None
Oral
Dab-on
Other
Flea prevention #2
None
Oral
Dab-on
Other
Prescription medications or medical issues.
Serious behavioural issues.
Issues applicants need to know
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Legal Matters
Registered with local council?
Yes
No
Registered with local council #2?
Yes
No
Shire
Shire #2
Registration number
Registration number #2
Ever bitten a person?
Yes
No
Was medical attention required?
Yes
No
Details
Include the name of the dog
Ever attacked another dog ?
Yes
No
Was vet treatment required for any involved?
Yes
No
Details
Include the name of the dog
Been declared a dangerous dog by authorities?
Yes
No
Been declared a dangerous dog by authorities #2?
Yes
No
Where did you get your dog?
Pet Shop
Breeder
Paper / Gumtree etc..
Pound
Rescue
Other
Where did you get your dog #2?
Pet Shop
Breeder
Paper / Gumtree etc..
Pound
Rescue
Other
Do you want to involve the breeder or rescue?
Yes
No
Name and contact details of the breeder or rescue.
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Behaviour
Likes male dogs?
Yes
No
Depends
Likes male dogs #2?
Yes
No
Depends
Details
Situations where dog is anti social, anxious, territorial, reactive etc..
Likes female dogs?
Yes
No
Depends
Likes female dogs #2?
Yes
No
Depends
Details
Situations where dog is anti social, anxious, territorial, reactive etc..
Proven to live safely with cats?
Yes
No
Depends
Proven to live safely with cats #2?
Yes
No
Depends
Details
Detail if in harmony, prickly, certain conditions etc...
Other animals?
Yes
No
Other animals #2?
Yes
No
Details
Trusted around kids?
Yes
No
Trusted around kids #2?
Yes
No
Details
Defensive of food, may knock a small child over, is frightened of noise etc...
Exercise requirements?
Super low - prefers to be carried
Low - short strolls or playtime at home
Medium - playful and moderately active (can miss a daily walk)
High - will run and run, cannot miss a day
Exercise requirements #2?
Super low - prefers to be carried
Low - short strolls or playtime at home
Medium - playful and moderately active (can miss a daily walk)
High - will run and run, cannot miss a day
Details
When on a lead this dog ...
is well behaved
starts off pulling but settles
ok unless distracted
pulls and battles
When on a lead this dog #2 ...
is well behaved
starts off pulling but settles
ok unless distracted
pulls and battles
Details
May pull a small person over etc..
When off the lead this dog ...
will stay close by and come when called
is sometimes good and sometimes bad
takes off and won't come back
When off the lead this dog #2 ...
will stay close by and come when called
is sometimes good and sometimes bad
takes off and won't come back
Details
Escape artist?
Jumps over or digs under fencing, climbs, wanders, darts through open doors etc...
Nuisance barker?
Destructive?
Toilet Trained?
Tolerance to being alone during the day?
People and/or humans
My dog(s) like ...
My dog(s) dislike / fear ...
Describe the ideal home
Consider space, company, exercise, families with kids, active seniors etc...)
Anything else to help us understand your dog(s)' needs and personality
Quirks, habits, routines, endearments, etc...
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General
Food - what and when?
What do YOU LIKE about your dog(s)?
What do YOU DISLIKE about your dog(s)?
Why are you re-homing your dog(s)?
We don't judge - please be honest
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Time Frame
DOG ADOPTION is committed to finding your dog(s) new loving and safe homes - but we can't pin-point how long it will take. We always find a solution. This may happen quickly or take longer then expected. All dogs have the same priority.
The dog(s) need to be re-homed by:
as long as it takes
as a priority but not urgent
firm deadline without extension
Deadlines cannot be guaranteed
Deadline date
Deadlines cannot be guaranteed
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Advertising
By agreeing here you authorise DOG ADOPTION to publish the dog(s)' name and suburb as listed in this form and also to publish any photos and/or movies sent to DOG ADOPTION by you or any third party.
Agree
Disagree
I authorise DOG ADOPTION to publish the dog(s) profile on (we recommend you select all):
any website
social media
emails / flyers
newspapers, radio, TV (unlikely to be available)
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Surrender Agreement
Effective from the time your dog(s) leaves your premises and goes into the care of your approved adoptee.
I do hereby surrender to the approved adoptee, the dog(s) named:
Insert dog(s) name
I certify that I am the owner of the dog(s), free and clear of all other interests. I also certify the information I have provided about the behavioural and medical history of the dog(s) is true and complete to the best of my knowledge. I irrevocably relinquish unto the approved adoptee all rights, title and interest in and to the dog(s) surrendered. I hereby forever release, discharge and agree to hold harmless and indemnify the DOG ADOPTION program, its members and agents from all claims, demands, actions, causes of action and liability of any kind whatsoever arising as a result of or in connection with the surrender and subsequent adoption or other disposition of this surrendered dog(s). I have read the above, I understand and agree to it.
Agree
Disagree
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Terms and Conditions
Date
-
Day
-
Month
Year
Date
Signature
Total Payable
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