Test Adoption Application Step 1 of 7 14% Basic InfoName* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone*Email* Is there another person responsible for the dog's care?* Yes No Name Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Housing InfoAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How many years have you lived at your current residence?*Less than 11 to 33 to 55 to 1010+Previous Address* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you own or rent?*OwnRentLandlord Name* First Last Landlord Email* Landlord Phone*Type of housing*Single-Family HomeApartment high-riseApartment low-riseCondoTown-houseMobileOtherAre you moving in the near future?*YesNoN/AWhat is your future address?* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please list all people and age who reside in home over 18*Please list all minors (under 18) and age who reside in home*Please list the ages and genders of regular visitors to the home*Are all persons in household on board to adopt a dog?*YesNoN/ADoes anyone in the home have any known allergies?* Yard DetailsDo you have a backyard?*YesNoSize of Backyard* Do you have a front yard?*YesNoSize of front yard* Do you have a fence?*Yes, BothYes, Just in the backyardYes, Just in the front yardN/APlease provide details of the fencing typeType of Fence (e.g. Wood slate privacy fence, Chain link fence, Picket fence)Height (in ft)3 feet4 feet5 feet6+ feetN/AIs fence secure on all sides of yard?YesNoN/ASince your fence is not secure, Please explain Vet ReferencesName of Veterinary Practice Veterinary PhoneVeterinary Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Personal References#1 - Personal Reference Name* First Last (non-family member)Personal Reference Phone*Personal Reference Email Relationship to Reference* #2 - Personal Reference Name* First Last (non-family member)Personal Reference Phone*Personal Reference Email Relationship to Reference* Information About PetsWhich ASCZ Dog are you interested in?* Is this your first dog?*YesNoDo you currently own one or more dogs?*YesNoPlease provide the breed, age, gender, a brief description of personality of current dog(s), and where obtained*How does your current dog(s) act towards visiting dogs (if known)?*Have you owned dogs in the past 10 years?*YesNoPlease provide any helpful information about past dog ownership prior to current dogs if applicable.Do you have any specific dog training experience? (Check All That Apply) House-Breaking Leash Skills Crate-training Special Needs Experience Leash Reactivity Timid Behavior Blind Deaf Hospice Other training experience?Do you own one or more cats?*YesNoPlease provide age, gender, and personality of your cat(s)*Please provide information explaining how your cat(s) act towards visiting dogs (if known)?*Do you have any other animals (e.g. birds, reptiles, fish, hamsters, guinea pigs, rabbits etc.)?*YesNoPlease list your other animals*Is there any livestock on your property? If yes, please list* Final DetailsSize* 5 - 35 lbs 35 - 55 lbs 55 to 85 lbs 85 lbs+ Check all that applyAge* puppy 3 to 5 months 5 months to 1 year 1 to 4 years 5 to 8 years 8 years + Check all that applyGender* Male Female Housebroken* Yes No Energy Level* Low Medium High Are you ready to adopt now?*YesNoSince you selected no, when will you be ready?* MM slash DD slash YYYY How many hours per day will the dog spend alone?* Where will the dog be kept at night? (check all that apply)* Free roaming inside Gated off area inside Crate Garage Outside Other Since you selected "other" please explain* Where will the dog be kept at day? (check all that apply)* Free roaming inside Gated off area inside Crate Garage Outside Other Since you selected "other" please explain* How did you hear about us?* Facebook Twitter Petfinder.com AdopAPet.com AllPaws.com Other Social Networks Google Bing Yahoo A Friend Other I understand the adoption fee for dogs 6 months and older is $450.* I agreeI understand the adoption fee for dogs under 6 months is $550.* I agreeI understand that my application will be reviewed as quickly as possible. An adoption coordinator will contact me with more information via email or phone within 72 hours.* I agree
