APPLICATION FOR DOG ADOPTION Applicant Name: First Last How did you hear about us?Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home PhoneCell PhoneEmail Enter Email Confirm Email Employer:Occupation:What type of dog are you interested in? Puppy <12 mos Adult 1-6 Senior 7+ years Name of dog you are interested in:Personality type:Other Preferences:How many people currently reside in your household?Please enter a number from 1 to 50.Any children in the household?None12345678910For Whom are you adopting the petSelfGiftDoes any member of of the family have allergies to animals?YesNoIf yes, explain:Who will be responsible for the pet's care?Where do you live?ApartmentCondoFarmMobile HomeTownhouseHouseDo you own or rent your residence?OwnRentIf you rent, what is name of landlord and phone number?Are pets allowed?YesNoNot SureWhere will the dog be kept?Indoors onlyOutdoors onlyBoth in/outIf outdoors will pet be?attendedunattendedcollar and tags?Will anyone be home during the day?YesNoHow many hours will the dog be left unattended?Please enter a number from 0 to 24.When no one is home, where will the dog be kept?Is your yard fenced in?YesNoDo you have a pool?YesNoIf yes, is it fenced/gated so that a dog can be kept away?YesNoIf you move, what will you do with the dog?How far from the road/traffic is you home/farm located?What is the volume of traffic?LightModerateHeavyHave you ever had a pet before?YesNoDescribe the pets you still care for or that are living in your household.NameBreedAgeNeutered?Time in your careUp to Date Vaccinations Are your pets current on their vaccinations?YesNoPlease provide name of your veterinarian:Veterinarian Phone number:Personal References:NamePhone NumberYears known Are you financially able and willing to provide annual checkups, vaccinations, and ANY medical care necessary? (Pets can live upwards of 15 years.)YesNoWhat precautions would you take to properly introduce a new pet into your home if you have other animals (a dog, bird, rabbit, cat, etc.)?What will you do if your new pet does not get along with your present pets?Have you ever adopted an animal from a rescue/animal control agency?YesNoWhy do you want to adopt a pet?Are you familiar with your local animal control laws?YesNoAre you willing to sign legal pet adoption papers?YesNoDo you agree to permit a visit to your home/farm by appointment?YesNoUnder which circumstances would you give your pet away or surrender to a shelter? Please select all that apply. If not listed, please indicate under “Other”. Not Obedient Enough Illness in family Pet became ill Moving New Baby Shedding too much Barking Chewing Too energetic Doesn’t get along with other dogs Divorce Got a new pet Allergies Housetraining problem Bit Someone Kids ignore pet Pets not getting along Got too old Doesn’t like all people Would not give pet away at all Other If other is selected above please describe:By signing this form, l/we acknowledge that all information on this form is true and correct. I/we understand that any misrepresentation of fact may result in Darbster Foundation refusing adoption privileges to me/us. If my/our request for adoption is approved and later Darbster Foundation discovers the above information is not true or correct, Darbster Foundation reserves the right to remove the adopted cat from my home/farm. If you have exhausted all reasonable efforts to keep your pet, Darbster Foundation accepts the return of any animal adopted from our facility. Adoption returns must be scheduled in advance and are accepted by appointment only. Guardians who wish to return their adopted animal should call 603-635-4495 or email email@example.com to schedule an appointment. Note- there will be an intake fee of $75 if the dog is returned after 14 days from the original adoption date. SignatureDate Date Format: MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.