Animal Connections Pre-Adoption Questionnaire

Animal Connections - Dog Adoption Questionnaire

2471 Troy Rd. Troy, VA 22974 (434) 589-3834 www.animalconnections.org

My Information

Date:	February 08, 2010
Name:
Home Phone:
Work Phone:
Cell Phone:
Street Address:
City:
State:
Zip Code:
Email Address:
Occupation:
Dog Interested In (Name/Description):

About My Home

Number of adults:
Do they all work outside the home?	Yes No
Who will be the dog's primary caretaker?
Number of children:
Ages of children:
Do children frequently visit you home?	Yes No
If yes, ages of children:
Is anyone in the family allergic to pets?	Yes, to dogs and cats Yes, to cats only Yes, to dogs only None of the above
If yes, who in your family is allergic and how severely?
Is anyone in the home nervous or unsure of dogs?	Yes No
If yes, who?
Living Circumstance:	I rent my home I own my home I live with parents/relative Other
If other, please use this space to explain
If renting, does your landlord allow pets?	Yes No
If renting, landlord's name:
Landlord's number:
How long have you lived at this address?
My Home Is:	In the city In the country In the suburbs In a mobile home park Apartment or condo complex
If applicable, name of mobile park:
If applicable, name of apartment/condo complex:
Will you allow an Animal Connections representative to do a pre-adoption visit to your house?	Yes No

Please List All Pets in Your Household

Pet 1		Pet 2
Name		Name
Type/Breed		Type/Breed
Vaccinated		Vaccinated
Age		Age
Sex		Sex
Spayed/Neutered	Yes No	Spayed/Neutered	Yes No
Kept Where?		Kept Where?

Pet 3		Pet 4
Name		Name
Type/Breed		Type/Breed
Vaccinated		Vaccinated
Age		Age
Sex		Sex
Spayed/Neutered	Yes No	Spayed/Neutered	Yes No
Kept Where?		Kept Where?

Please use this extra space to list more pets:

Have you had other dogs or cats in the past 5 years?	Yes No
If you selected yes, how many cats and dog?	Cats Dogs
Where are they now?

Do you have a veterinarian?	Yes No
Veterinarian name:
Veterinarian number:

My Preferences

I am looking for (check any that apply):	Puppy Young Adult Senior No Preference

I am looking for (check any that apply):	Small (5-25lbs) Medium (25-50lbs) Large (80-50lbs) Extra large (80+ lbs) No Preference

Would you prefer a:	Male Female No preference

Would you prefer your dog spayed/neutered:	Before adoption After adoption Prefer not to be fixed

Please check all reasons for adopting a dog:	Breeding Companion for self Companion for another animal Child's Pet Hunting Gift for someone outside the immediate family Guard dog for business Watch dog for home

Energy level of dog you are looking for?	Low Medium High

Please check what is necessary to you in a dog you will adopt:	Already housetrained Already knows basic obedience Doesn't pull on leash Can be left in the house unattended Can be walked off leash Doesn't jump up Rarely barks Doesn't dig Low-shedding Doesn't chew Likes to fetch/play Doesn't wander Will jog or run with me Gentle with young children Good watch dog Good with strangers Likes other dogs Good with cats Good with livestock Other

If you chose "other," please specify

Are you planning on taking your dog to obedience class?	Yes No
Are you prepared to spend $300-$500 a year on basic expenses (food, medical) for this dog?	Yes No
Where will your dog be kept?	Primarily indoors Indoors and outdoors Outdoors only

How many hours will your dog be left alone each day?	0-4 hrs 5-9 hrs 10+ hrs

Where will your dog be left alone?
Where will your dog sleep at night?

Dog will be exercised:	Fenced Yard Invisible Fence Outside Kennel Cable/Runner Stationary tie-out Unfenced yard Will leash walk dog

If unfenced acerage, how many acres?
If fenced yard, what kind?

Under what circumstances would you give up this pet?	Bites/aggressive Aggressive with other pets Wanders Difficult to housetrain Chews/destructive when alone Requires too much exercise Moving out of state Moving to a "no pets allowed" housing Medical expenses/dog ill Other

If you chose "other," please explain

Have you ever surrendered or returned a dog?	Yes No
If so, please explain:

Please supply the name, address, and telephone number of two personal references (non-relatives):

Reference 1			Reference 2
Name:			Name:
Address:			Address:
Phone number:			Phone number:

I certify that the information I have given above is true and correct, and I hereby authorize the above listed veterinarian to supply information in regard to my pets to the Animal Connections. I also give my permission to the Animal Connections provider to contact the above listed landlord and references.

Note: Once you hit the submit button, you will return to the dogs page and your application will be received by an Animal Connections representative. Please give at least 5-7 business days for your application to be processed. Animal Connections reserves the right to deny any application.