| What is the name of
the animal you are applying for? |
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| Name |
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| Spouse / Roommate Name |
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| Address |
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| City, State, Zip |
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| Home Phone Number |
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| Work Phone Number |
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| Email Address |
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| Occupation (all applicants) |
Primary Applicant:
Spouse / Roommate:
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| Do any children live in, or visit, your home? |
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| If yes, what are their ages? |
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| If no, do you plan to have children in the future? |
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| Does Everyone in my household wants the dog? |
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| Is anyone in the household allergic to animals? |
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| What type of home do you live in? |
Other Type of Home:
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| Do you own or rent your home? |
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| If you rent, you must have landlord's permission to
have a dog. Please provide us with your Landlord Info. |
Landlord Name:
Landlord Phone:
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| Do you have a fenced yard? |
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| Please describe your fence: |
Type:
Height:
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| Can people passing by see behind your fence? |
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| Do you have a swimming
pool? |
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| If yes, is the pool
fenced? |
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| Dogs frequently drown in
pools. If your pool is unfenced, how do you plan to protect
this dog? |
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| Do you have a pond or
jacuzzi in your yard? |
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| Do you currently own any pets? |
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| If yes, please provide the following information
about each pet: |
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| Have you owned other dogs in the past? |
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| If yes, how many? |
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What happened to these dogs? (Be specific)
If deceased, please state the cause of death and how long ago. |
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| How did you obtain your previous pets? |
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| Please provide the following information for your
current or past veterinarian: |
Veterinarian / Clinic Name:
Address:
Phone Number:
No current or past veterinarian |
I agree to advise my vet that you will be
phoning for medical information on my previous and current pets and
we will also notify you when we have done so. I understand that this
application will not be processed until this occurs. If I have had
no previous pets/veterinarian services, this does not apply.
Check if agree
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| Please provide the following information for your
current or past groomer with previous/current pets: |
Groomer Name:
Address:
Phone Number:
No current or past groomer |
| Have you ever given up a
dog? |
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| If yes, please explain: |
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| Why do you want this dog?
Please number as many
choices as apply in order of importance. |
For my children
As a companion for me
For protection
To give as a gift
As a companion for my other pets
Hunting
Guard dog
Other. Please explain:
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| Why did you choose this
dog? |
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| How did you learn about this dog?: |
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| Are you willing to housebreak this dog? |
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| How do you plan to exercise this dog? |
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| Do you object to an inspection of your premises by
an FCIA representative? |
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| Who will be responsible
for the care of this dog? |
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I realize that dogs require annual vaccinations and
routine medical care.
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Check if agree
I estimate the cost to be about $ per
year. |
I realize that at some time my dog may become sick
or injured.
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Check if agree
I am willing or unwilling to provide the
additional medical care if needed. |
| What is the maximum you expect to pay for medical
per year? |
$
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| I realize that dogs may
live for 12 to 15 years or more |
Check if agree |
| Do you agree to have
this dog spayed or neutered (if not already) |
If not, why not?
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| Do you agree to have
this dog licensed with your City / County? |
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Under what circumstances
would you not be able to keep this dog?
(Check all that
applies) |
Divorce
Move
New Baby
New Job
Illness
Other. Explain:
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| What would happen to
your dog should something happen to you during its lifetime and you
could no longer care for it? |
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| Is there someone who
could take this dog and care for it? If so, who? |
Name:
Address:
Phone:
What type of pet do they currently
have?
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| Are you a frequent
traveler? |
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| If yes, how will you
provide care for this dog while away? |
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| I understand that the
initial adjustment period between a dog and its new owner is
critical.
How long do you plan to be with this
dog before being left alone for any period of time? |
Hours
Days |
| How many hours per day
will this dog be left alone? |
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| When you are away, where
will this dog stay? |
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| While you are at home,
where will this dog stay? If
both (indoors & outdoors) how long with this dog be inside and how
long outside? |
Time outside:
Time inside:
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| Please describe the
outdoor shelter you have for this dog: |
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| Where will this dog
sleep? (Be specific) |
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| Will this dog have a
doggie door? |
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| If no doggie door, how
will this dog be able to get in and out of the house? |
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| I realize that dogs
frequently left alone will dig, chew & bark.
How will you deal with these potential
problems? |
Check if agree
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| Do you allow your dog(s)
to run and play in public places (beach, park, etc) without a leash? |
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| Are you willing to take
this dog to obedience classes, if necessary? |
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| Would you welcome more
information about health, safety and training information for this
dog? |
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I understand that
no adoption is officially approved unless signed by one of the Board
of Directors of the Foundation for the Care of Indigent Animals (FCIA). |
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BY SUBMITTING THIS APPLICATION, I CERTIFY THAT THE
ABOVE INFORMATION IS TRUE, AND THAT ANY FALSE INFORMATION MAY RESULT
IN NULLIFYING THE APPLICATION. |
