Test

Basic Info
Name*
First Middle Last
Date of Birth*
Phone*
Phone (secondary)
Email*
Email (secondary)
How did you hear about us?*
Please list name / source
How may we reach you?*
- Select All
- Email
- Phone
- Text
Select all that apply
Before you begin...
I am at least 24 years of age or reside with an adult that is at least 24 years of age and is on board with pursuing adoption of a dog.*
- Yes
- No
I am ready to adopt within the next 30 days.*
- Yes
- No
Please provide date
MM slash DD slash YYYY
All adults in the resident are on board with adopting a dog. We are all in agreement in the pursuit of a canine companion for our household.*
- Yes
- No
Is there another person responsible for the dog's care?*
- Yes
- No
Name
Date of Birth*

Housing Info
Home Address*
Street Address Address Line 2 City State ZIP Code
Are you listed as the owner of the home?*
- Yes
- No
- N/A
How many years have you lived at your current residence?*
Previous Address*
City State ZIP Code
Do you own or rent?*
Landlord Name*
First Last
Landlord Email*
Landlord Phone*
How many residents over 18 reside in the home (including you)?*
How many residents under 18 reside in the home?*
Ages of residents under 18 if applicable
Are there known animal allergies?*

Yard Details
Check all that apply. I have a:*
- Private Backyard
- Private Front Yard
- Private Patio Area
- Private Balcony
- Shared yard space
Check all that apply. I have a:*
- Fenced in Front Yard
- Fenced in Back Yard
- Full Yard is fenced in
- No fence
Please provide details of the fencing type
Type of Fence (e.g. Wood slate privacy fence, Chain link fence, Picket fence)
Height (in ft)
Is fence secure on all sides of yard?
Since your fence is not secure, Please explain

References
We strongly recommend that you give your personal references a head’s up that we might be calling or emailing them. In addition, we recommend that your vet has your permission to release vet information to rescue organizations.
Name of Veterinary Practice
Veterinary Phone
Veterinary Address
Street Address Address Line 2 City State ZIP Code
When was your last visit to this practice, approximately? (Month/year)

Personal References
We strongly recommend that you give your personal references a head’s up that we might be calling or emailing them. In addition, we recommend that your vet has your permission to release vet information to rescue organizations.
#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 Pets
Which ASCZ Dog are you interested in?*

If there isn’t one in particular, we can still help you
Do you have dogs in your home currently?*
Please list name, gender, age, breed mix*
Will this be your first dog?*
Please 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)*
- Housebreaking
- Crate training
- Timid Behavior
- Leash Training
- Leash Reactivity
- Dog to Dog interaction
- Resource Guarding
- Special Needs
- Other
Other training experience?
Do you have cats in your home?*
Please provide age, gender, and personality of your cat(s)*
Do you have other animals (including livestock)?*
Please list your other animals*

Basic Info