Dog Adoption Application Dog Adoption Application Name(Required) First Last Age(Required)Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email Drivers License #(Required)State(Required)Do you rent or own?(Required)Landlord name/number if applicableHow long have you lived here?Are you currently employed?(Required)Where do you work?How long have you been employed at this job?Spouse/partner InfoSpouse/ Partner Name (Leave blank if not applicable) First Last Address (Leave blank if same as above address) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Drivers License #StateHouseholdList all members living in the household(Required)NameAgeRelationship to you Add RemovePlease list all current and past pets owned in the last 5 yearsAnimal TypeBreedNameAgeM/FFixed?Living or deceased Add RemoveVet InfoPlease provide your vet/clinic that has up to date vaccination records for any current animalsPhone numberAddressGeneral InfoHave you ever surrendered a pet? If so, why?Have you ever euthanized a pet? If so, why?Does anyone in your residence have a known allergy to any animals?Will the dog have full run of the house, or be kept from certain areas?About how many hours a day will the dog be left alone?Do you plan on crate training/ crating the dog?Do you have a fenced in yard? If so, how tall?If you do not have a fenced in yard, will you be leash walking only or letting the dog free roam?If there are no kids or other animals living in the residence currently, do they visit frequently?Do you travel often?If so, will the dog come with you, be boarded, or will other arrangements be made?Is there a specific dog you are interested in?If not, what breed/age/size are you looking for?Are you willing to let a PCHS staff member visit your home by scheduled appointment if necessary?Signature(Required)
