Dog Application

Thank you for your interest in adopting a pet from the Montgomery County SPCA! 

Please complete all sections of this application.

 

PLEASE PRINT   

 

DATE ______________________________        Name of dog you are interested in _________________________________________________________________________

APPLICANT _________________________________________________________________________________________________________________________________

CO-APPLICANT ______________________________________________________________________________________________________________________________

ADDRESS __________________________________________________________________________________________________________________________________

CITY_________________________________________________    STATE ______________      ZIP ______________    How long at this address? ________________________

PHONE: home ____________________________________     work ____________________________________     cell _________________________________

EMAIL ADDRESS ___________________________________________

EMERGENCY CONTACT NAME (Not in same household):  ________________________________________________ EMERGENCY PHONE  _______________________________

Do you rent?   □NO  YES   If YES, please provide the following:

LANDLORD’S FULL NAME _______________________________________________________________________________________________________________________

ADDRESS ___________________________________________________________________________________________________________________________________

CITY_____________________________________________________________    STATE _____________________      ZIP ___________________________________

PHONE: home _____________________     work _____________________     cell ______________________________   Does your landlord allow pets?   □NO  YES

Applicant’s Employer ________________________________________________________________________Supervisor’s name:__________________________________

Address  _________________________________________________________________________________________________________________________________

City _____________________________________________________________________    State ____________________    Phone _______________________________

Co – Applicant’s Employer _____________________________________________________________________Supervisor’s name: _________________________________

Address  _________________________________________________________________________________________________________________________________

City _____________________________________________________________________    State ________________   Phone ___________________________________

Name(s) of other adults in your home who will be responsible for the care of this pet: __________________________________________________________________

Number of adults in your home: __________  Number of children in your home ____________ Children’s ages: ____________________________________________

Do children visit regularly?   □NO  YES  

Other pets in your home:

1.  Name: ___________________________________________________        Age: __________     Temperament: ______________________________________________

Dog   □Cat  Other___________         Sex: Male  Female        Altered: NO  YES     Rabies current? NO  YES

2.  Name: ___________________________________________________        Age: __________     Temperament: ______________________________________________

Dog   □Cat  Other___________         Sex: Male  Female        Altered: NO  YES     Rabies current? NO  YES

3.  Name: ___________________________________________________        Age: __________     Temperament: ______________________________________________

Dog   □Cat  Other___________         Sex: Male  Female        Altered: NO  YES     Rabies current? NO  YES

4.  Name: ___________________________________________________        Age: __________     Temperament: ______________________________________________

Dog   □Cat  Other___________         Sex: Male  Female        Altered: NO  YES     Rabies current? NO  YES

Are you seeking a guard dog?  □NO    YES                How many hours per day will the pet be left home alone? ______________________________________

Where will the pet be housed?   □INSIDE   OUTSIDE   If OUTSIDE, describe shelter provided:_________________________________________________________________

Do you have a fenced-in yard?   □NO    YES                Are you considering crate-training the pet?  □NO    YES 

What kind of exercise will this pet be given? _____________________________________________________________________________________________________

Are you planning dog-training sessions with this pet?  □NO    YES    If YES, when? _________________________________________________________________________

Why do you want to adopt this pet? ___________________________________________________________________________________________________________

Are you committed to caring for this pet for a lifetime?   NO    YES  

Are ALL members of your household in full agreement to adopt and take responsibility for this pet?   □NO    YES  

Have you owned a pet no longer in your household? NO    YES   If yes, why is the pet no longer in the household? _________________________________________________

 Are you willing and financially able to provide all future vet care for this pet, including periodic exams, inoculations and emergency treatment required?   □NO    YES

Veterinarian ____________________________________________________________________________________       Phone _______________________________

Please provide two character references (non-family):

 Name ___________________________________________________________  Relationship ________________________     Phone ___________________________

Name ___________________________________________________________  Relationship ________________________     Phone ___________________________

By signing: 

*  I/We affirm that the information provided by me/us in this application is true to the best of my/our knowledge.  I/We understand that any misrepresentations of fact may result in the removal of an adopted pet from my/our home by the MCSPCA.

*  I/We understand that if I/we are approved for adoption, I/we will be required to make a substantial commitment of time and money for up to 15 years for the adopted pet.

*  I/We authorize release of information to theMontgomeryCountySPCA of any police and veterinarian records.

 

APPLICANT SIGNATURE ______________________________________________________________________________________________________________________

CO-APPLICANT SIGNATURE ___________________________________________________________________________     DATE __________________________________

Revised  5/2012

FOR STAFF USE ONLY   

Name of staff/volunteer who assisted interested adopter_________________________________________________________         Date__________________________

Preferred date/time for Home Visit _______________________________________      Date/time of Home Visit_________________________________  □  Shelter         PetSmart