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Dog Adoption Application
*The adoption fee includes spaying/neutering, vaccinations, deworming, vet health check, and feline leukemia testing.
Date of Application
First Name of Applicant
Last Name of Applicant
First Name of Co-Applicant (Spouse or Other)
Last Name of Co-Applicant (Spouse or Other)
Email address:
Phone Number
Street address:
City:
State:
Country:
Name of dog being applied for:
Breed:
Gender
Choose an option
Name of 2nd choice of dog:
Breed:
Gender
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This Pet is For
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If other, explain
This pet will primarily be a:
Choose an option
This pet will primarily be:
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If other, explain:
Do you have a fenced in yard?
Choose an option
If yes, what type of fence do you have?
Will this pet be tied up outside?
Choose an option
If other, please explain:
I live in:
Choose an option
My residence is:
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Landlord Name:
Landlord Phone Number:
My residence is a/an:
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If other, please explain:
Do you operate a daycare?
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Do you have any pets currently?
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If yes, how many cats?
If yes, how many dogs?
Other pets?
If you don't currently have any pets, have you had any in the past?
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If yes, what kind of pets did you have and when?
What happened to them?
Have you adopted from JRHS or another similar facility before?
Choose an option
If yes, what kind of pet did you adopt and when?
Number of adults in your household:
Number of children in your household:
If you have young children, will they be allowed to play with the pet/pets unsupervised?
Choose an option
If yes, explain:
Will you provide the pet for which you applying for the necessary vaccinations for its lifetime?
Choose an option
If the pet becomes ill or injured, will you provide treatment and/or medications as prescribed by a vet?
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Will you provide collars and ID tags to ensure the pet's safe return should it become lost or stolen?
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Have you ever been convicted of or accused of any crime against an animal, such as abuse, neglect, or abandonment?
Choose an option
If yes, explain:
Please provide any other comments/information that may help us make our decision on this adoption?
List a reference (past or current veterinarian - if this is not applicable to you, please provide the name of an employer):
Vet's (or employer's) phone number:
Submit
Thanks for applying!
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