(No relatives, please)
Type Of Dwelling: House Apartment Condo Mobile Home Duplex
How Long At This Address? (If less then 1 year please specify your previous address)
Do you? Own Rent Do you have your landlord's permission to have a dog? Yes No
Landlord's Information: First Name: Last Name: Phone Number:
Do you currently have a fenced yard? Yes No If yes, please specify the heights (Check all that apply): Under 4 Ft 4 Foot 5 Foot 6 foot or higher
and the types (Check all that apply): Chain Link Privacy Invisible Other:
If you do NOT have a fence, how do you plan to handle exercise and toilet duties: Please explain in detail Are you familiar with crating?: Yes No If yes, what are your feelings about crates?:
Please list the following information for each person, other than the applicant above who will be living in the household with dog(s).
Who will be the primary caregiver of the dog?:
Is everyone in the household aware of and agreeable to your interest in adopting?: Yes No
Have you ever owned any cats?: Yes No (If no please move forward to Canine Ownership section) How many cats have you owned in that last 10 years?: Briefly describe what happened to the cats you no longer have: How many cats do you currently own?: Are they indoor or outdoor cats?: Indoor Outdoor Both Are your cats declawed? Yes No Briefly describe your cat's interaction with dogs:
Have you ever owned dogs?: Yes No (If no please move forward to Other Pet Ownership section) How many dogs have you owned in the last 10 years?: Briefly describe what happened to the dogs you no longer have: How many dogs do you currently own?:
If you currently have dogs please list the following: Dog's Name: Sex: M F Age: Breed: Spayed/Neutered?: Yes No
Dog's Name: Sex: M F Age: Breed: Spayed/Neutered?: Yes No
Other Pet Ownership: (If you currently do not own any other pets please proceed to the next portion of the application)
Please list all other animals:
Do you have a regular veterinarian?: Yes No
Vet Reference:
Organization Name:
Vet's First Name: Vet's Last Name:
Address: City: State: Michigan Alabama Alaska Arizona Arkansas California Colorado Conencticut Delware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennslyvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:
Phone Number: Fax Number:
Is this the vet you currently use?: Yes No
If this is not your current vet, please explain:
Are you familiar with heartworm disease?: Yes No Somewhat
Do you currently practice the prevention of heartworms in your animals?: Yes No
If yes, what medication do you use?: How often?:
If no, please explain why not:
Name of the dog you are applying for?:
Why have you chosen to this breed?:
Are you willing to obtain and crate-train your dog if necessary?: Yes No If Not, why?
Are you willing to take your dog to basic obedience class?: Yes No If not, why?
Do you have the time to house train a dog?: Yes No If not, why?
What would you do it your dog bit somebody?
Do you have a preference? Sex: Male Female Age: Color:
Would you consider a mix? Yes No
Energy level preference (check all that apply): High Energy Outdoorsy Lap Dog Athletic (Hiking, mushing) Quiet Very Affectionate Couch Potato Spunky Adventurous Sled Dog
Please indicate what, if any, personality traits you are seeking in your new dog:
Where will your dog spend the day? (Check all that apply): Loose indoors Garage Outside in kennel run Loose outdoors Tied up outdoors Crate Basement Other
Where will your dog spend the night? (Check all that apply): Loose indoors Garage Outside in kennel run Loose outdoors Tied up outdoors Crate Basement Other
How many hours will your dog spend alone?:
Is someone home during the day?: Yes No
What are your work hours?:
Who will care for your dog while you're on vacation?:
Do you agree to allow a representative of Closer To Home Animal Advocates to visit your home by appointment?: Yes No
How did you hear about Closer To Home Animal Advocates?:
Please let us know if you have any other information which you wish us to consider when evaluating your application (if you are applying to FOSTER please note that here):
I understand that owning a dog is a commitment for the dog's lifetime and if I adopt a dog from Closer To Home Animal Advocates, I are willing to make that commitment. I Agree