Name

Home Phone Cell Phone Email

Driver's Licence #

How long have you been thinking aobut adopting a pet

Who are you adopting this pet for?

What type of personality are you looking for in this pet?

Primary care giver of this new pet will be

Do you plan to place a collar/ name tag on this pet? Yes No Do you plan to keep the pet? Yes No

Do you live in a? How long have you been in this residence?

Do you rent? Yes No

Do you anticipate moving in the next 6 months? Yes No

Name of animal interested in

How long have your been at your present job?

Occupation Work HoursWork Phone

How often do you travel?

Who will care for your dog while you are away?

Address City State Zip

If yes, do you have landlord’s permission to keep a pet? Yes NoMay we contact your landlord? Yes NoLandlord's Name Landlord's PhoneIf you move, have you considered that another place may not allow pets? What will you do?

How many people in your household: 0Adults 0Children 0Regularly Visiting Children

Why are you looking to adopt thispet (chose all that apply )

House dogOutside dog

Hunting dogCompanion

For a childProtection

Companion for another pet

What activities do you want to do with your pet?

What reasons would cause you torelinquish this dog?

human agressionanimal aggressionhousetraining problems

excessive chewingseperation anxietymoving

having a babyOther…

How will you correct behavior problems in your dog if they occur?

Where will you keep your dog during the day when you’re at home?

Where will you keep your dog during the day when you’re gone?

Do you have a pet door? Yes No Do you have a fenced yard? Yes No

Long Beach Spay & Neuter FoundationDog - Pet Adoption Questionnaire

SelfOther Pet

Spouse ChildrenOtherGift

Vet Address

Vet Name Vet Phone

What type of food do you plan to feed this pet?

Would you object to a home visit? Yes No

How many hrs per day will your pet have human company?

Have you ever had to give up a pet? Yes NoIf yes, please explain why and what happened to the pet?

If anyone in your household is, or becomes allergic to pets what will you do?

Are you open to us visiting the dog once it’s settled in your home &/or grown up? Yes No

Do you have a relative or close friend who would adopt the pet if you become incapable of taking care of it? Yes No

SignatureDate Signature

Where will you keep your dog during the night?

Yes No If yes, how long daily

Will you commit to caring for your new dog for the next 10-15 years? Yes No

Name vet records are listed under?

Do any of your current pets have medical/behavior issues? Please explain:

Have you ever had a pet Run away Hit by a car Die in your care Kept as an outdoor pet

Please explain:

Thank you for Completing this ApplicationRelease:By submitting this document you are stating that all the information given herein is accurate and complete and that you are hereby giving your consent for LongBeach Spay & Neuter Foundation to verify any and all information. The completion of this forum does not entitle you to any guarantees or rights. LBSN will not be held liable in any way for any animal, or its actions, once the animal has been placed.

How long will you allow your dog to adjust to your home?