Dog Adoption Application

HART Dog most interested in: Date:

Why did you choose this particular Dog?

Name:

Street Address:

Apartment No.:

City, State, Zip:

Phone:

(Home):

(Work):

(Cell):

Email:
Referred By:

Children: #

Age(s):

In Future: Yes No

Total number of people in the household (roommates, etc.):

Please list the members of your household and their relationship to you (roommates, husband, children, mother, etc.):

Home Environment

Own Rent

If RENTING, does lease allow Dogs? Yes No

Fenced Yard? Yes No

If No, willing to fence? Yes No

If Yes, Fence Type Fence Height

Do you currently have or plan to have a doggy door? Yes No

Rural Suburban Urban

Single Family Home Apartment Townhouse Condo

How long have you resided at this location?

Place(s) of employment of adults in family: How long?

Any plans to transfer to another location or change employment in the foreseeable future?

1. How many hours a day will your HART Dog be left alone during the day? 0-5 hrs 6-8 hrs 9-12 hrs 12+ hrs

2. Where will your HART Dog be kept when you're not home?

Outside Crated Free Roam of House Enclosed Kitchen Basement
Other, please explain:

3. Where will your HART Dog be kept when you are home?

Outside Crated Free Roam of House Enclosed Area Basement
Other, please explain:

4. Describe when/where you will walk/exercise the Dog on leash:

5. List all places where the Dog will be allowed to have off leash exercise:

6. How much time do you realistically have each day to exercise or play with your HART Dog?

7. Who will care for your Dog while you are on vacation/travel?

8. Approximately how many weeks a year are you away from home on business or vacation travel?

0-2 weeks 3-4 weeks 5-6 weeks 7+ weeks

9. How will you encourage and reinforce appropriate behavior?

10. Are you willing to take your HART Dog to Obedience Training? Yes No

11. Have you ever taken a formal obedience class with your dog(s)? Yes No

12. If you have had a dog or cat, did you ever have to deal with any behavioral issues (such as housebreaking, chewing, separation anxiety)? If so, please list the issue(s) you have encountered/dealt with:

13. How will you prevent/manage inappropriate behavior?

14. What do you foresee as normal Dog problems?

15. Will your HART Dog ever be left outside unattended when you are not home?

Sometimes Always When weather is nice Never
Other:

16. What will you do with your Dog if you have to move?

Find New Home Take Dog on Move Take to local Animal Shelter Return to HART
Other:

Finding the Perfect Match

1. Why do you want a Dog? ProtectionFriend/CompanionFor Children

2. Who will be the primary/sole caretaker of the Dog?

3. What size Dog appeals to you? Tiny Small Medium Large

Weight limit?

4. What Age most appeals to you? Puppy Young Adult Adult Senior

5. What aspect of a Dog is MOST important to you?

(Please rate 1-7: 1= MOST Important 7= LEAST Important)
Appearance	Low Maintenance	Companionship	Agility
Obedience	Adaptability	Game Player

6. What activity level MOST appeals to you? High Medium Low

7. Type of Coat: Long Short No Preference

Is someone in the family willing to brush your HART Dog often? Yes No
How much do you think it costs to have your HART Dog Groomed? $

8. Does anyone in your family have allergies to dander/hair? Yes No

If yes, please explain:

9. Where will your HART dog sleep?

10. How much do you think it costs ANNUALLY to own a Dog?

Veterinary: $
Food, supplies, etc: $

11. Will you give your HART Dog Heartworm Preventative EVERY MONTH? Yes No

12. What causes Heartworm in dogs?

13. Please check the following that you think may apply: I would consider giving my dog back to HART:

if my work schedule changes dramatically and I no longer have sufficient time for the dog
if I have children in the future and no longer have sufficient time for the dog because of the demands of parenting
if other changed circumstances prohibit me from having sufficient time for the dog
if someone in the household becomes allergic
if I become ill and can no longer take care of the dog
if I lose my job
if I divorce or separate from my spouse/partner
if my new significant other/spouse doesn't like the dog
if the dog sheds excessively
if the dog is not housebroken
if the dog is or becomes aggressive
Other:

Pet History

1. Have you ever owned a Dog/Cat/Other Pet (Please do not include family pets from childhood)? Yes No

If Yes, please list:

Pet Name: Breed:
	Gender: M F Was pet spayed or neutered? Yes No
	Where did you get the pet?
	# years pet with family: Current Age of Pet:
	Is pet still with your family? Yes No
	If No, what happened to the pet?

Pet Name: Breed:
	Gender: M F Was pet spayed or neutered? Yes No
	Where did you get the pet?
	# years pet with family: Current Age of Pet:
	Is pet still with your family? Yes No
	If No, what happened to the pet?

Pet Name: Breed:
	Gender: M F Was pet spayed or neutered? Yes No
	Where did you get the pet?
	# years pet with family: Current Age of Pet:
	Is pet still with your family? Yes No
	If No, what happened to the pet?

Pet Name: Breed:
	Gender: M F Was pet spayed or neutered? Yes No
	Where did you get the pet?
	# years pet with family: Current Age of Pet:
	Is pet still with your family? Yes No
	If No, what happened to the pet?

Pet Name: Breed:
	Gender: M F Was pet spayed or neutered? Yes No
	Where did you get the pet?
	# years pet with family: Current Age of Pet:
	Is pet still with your family? Yes No
	If No, what happened to the pet?

If you have owned more pets than listed here, please inform the HART representative that contacts you.

Any additional comments you would like to make concerning pets you have owned?

2. What Veterinarians or Veterinarian clinics have you used in the past for your pets? Please list the names and numbers of all clinics, even if they are outside the local area and provide phone numbers if possible:

Vet	Phone	Pet Name(s)

3. What Heartworm medication have you used in the past for your dogs?

4. Have you ever incurred extraordinary medical expenses for your pet? Yes No

If Yes, please explain 1) what the extraordinary expenses were for; and 2) some of the expenses associated with the treatment:

5. Have you ever had to give up a Pet (Dog/Cat/Other) for any reason? Yes No

If Yes, what happened to the Pet:
Took to local shelter Found New Home
Other:

Will you permit a home visit by a HART Representative? Yes No

Do you authorize a vet check by a HART Representative? Yes No

How did you hear about HART?

Newspaper Friend Internet Petco Petsmart
Other:

When you click Submit, your application will be forwarded to a HART representative. You will also receive an automated email copy of your application. Please print this email copy and bring it with you to Adoption Day!