Please List Which Dog You Want to Adopt *
Application Information
First Name *
Last Name *
Street Address *
City *
State *
Zip *
Phone 1 *
Phone 2
Email Address *
What are your work hours / days? *
Occupation *
Name of additional responsible adult in household.
Occupation
Phone Number
Type of home; *
Single Family House Multi Family House Apartment Condo Live with Friends/Family/Roomates Mobile home Other (explain)
If other, please explain
Do you rent or own? *
Rent Own
If you rent, please provide your landlord name and their phone number. Also please email a copy of your lease to the adoption counselor.
How long have you lived in your current home? *
How many adults in your household? *
How many children? *
Ages of children: *
If moving becomes necessary, what will you do with your pets if you can not find a residence that allows pets? *
Are any members of your household allergic to animals? *
No Yes
Does everyone in the household agree with adopting a dog? *
No Yes
Is this dog a gift? *
No Yes
What is the activity level in your home? Select all that apply. *
Quiet, 2 or less adults/seniors, no children, applicant(s) home most of the time
Calm, Applicant(s) often home, 3 or less family members residing in the home, no young children
Moderate, Applicant(s) work typical schedule (5 days per week, home most weekends)
Active, Frequent visits by friends/family, multiple children, other pets, busy weekends
Other Pets
List pets that you own, or have owned in the past 5 years. Please list animal type, age, gender and if you still own them. *
Are your pets spayed/neutered? *
No Yes
If your pets are not spayed/neutered please list reason. *
Are all your pets up to date with vaccines? *
No Yes
If your pets are not vaccinated please list reason.
If you have a dog is it current on heart worm preventatives *
Yes No N/A
How much time do your dogs spend outdoors? *
Personal References
Please provide first personal reference *
Reference phone number *
Please provide second personal reference *
2nd reference phone number *
Please provide third personal reference *
3rd reference phone number *
Veterinary Information
Please provide the name of your Veterinarian. *
Name of clinic or hospital *
City
State
Phone number *
Please list any other vets or vet hospitals, 24-hr emergency clinics or vaccine clinics that you have used for your current or recently deceased pets.
New Dog Information
Why are you interested in adopting a dog at this time? Select all that apply. *
Companion to me/family
Companion for another pet
Breeding
Other (please explain in next box)
Other (please explain)
What age dog are you looking for? (Select all that apply) *
Puppy
Young
Adult
Senior
What gender do you prefer? *
Male
Female
Doesn't matter
What size do you prefer?
Small (5-25 lbs)
Medium (25-40 lbs)
Large (40+ lbs)
Doesn't matter
What type of personality and activity level would you prefer your new dog to have? Please describe. *
Who will be primarily responsible for the care of this dog? *
What type of food will you feed your new dog and how often? *
How many hours per day will the dog/puppy be without human companionship? *
Where will your dog sleep at night? *
Where/How Will Your New Dog Spend Time Outdoors? (Select all that apply.) *
Leash Walk Only
Off Leash
Tie Out/Runner
Invisible Fence
Fenced Yard
Unfenced Yard
No Yard
Outside when people are home to supervise
Outside anytime including when family is away from the home
Other (Please explain)
If other, please explain.
How do you plan to exercise your dog? *
Do you think your pet should have a yearly physical exam? *
Yes No Not sure
Are you planning on starting a new family? *
No Yes
Do you believe you can provide a home for your pet for its lifetime which could be up to 20 years or more? *
No Yes
How much would you estimate expenses to be for 1 year for dog supplies? *
How much do you estimate veterinary costs will be for 1 year? *
What arrangements would you make for the care of your dog/puppy when you go on vacation? *
Choose under what circumstances might you decide not to keep you dog or puppy? *
New Job
New Baby
Problem with dog's health
Problem with dog's behavior
Illness/Allergies
Conflict with other household pets
Moving
Monetary Issues
Chewing or Scratching
None
Other (Explain)
Have you ever adopted a dog from and Animal Shelter, Pound or Rescue organization before? *
No Yes
If yes, please list rescue(s) you have adopted from.
Have you ever surrendered an animal before (to a shelter / rescue / friend / family? *
No Yes
If yes, please explain.
Have you ever taken a dog to obedience class? *
Yes No N/A
Have you ever crated trained a dog? *
Yes No N/A
Would you allow a POA representative to do a home visit? *
No Yes
If no, please explain
Are you aware that if you adopt a dog, you will need to be aware of and abide by your town's leash law? *
No Yes
Are you aware that if you adopt a dog, you will need to license your dog with your Town with in a month of taking ownership? *
No Yes
Behavior problems can arise for many reasons; most can be solved. Do you agree to seek POA and/or professional help with any problems that may arise rather than give up on your pet should problems occur? *
Yes No Not sure
Would you accept an animal that has a treatable medical condition? *
Yes No Not sure
How did you hear about Protectors of Animals? *
Have you adopted from POA before, if so when? *
Preferred day/time for a follow up phone call regarding your application? *
