Dog Pre-Adoption Application Please complete this application if you would like to adopt a dog from BENCHS. You must be 18 years of age or older. A copy of your ID is needed to complete this form. Please provide staff with your driver s license or ID card upon submission of this form. All information provided must be accurate and legible. Forms that cannot be read or are incomplete will be discarded. Dog you would like to adopt Date Name: Address: City/State/ZIP E-Mail Primary Phone # Alternate Phone # Why would you like to adopt this dog? Companion for me and my family Companion for my other pets Watchdog/Farm dog Therapy dog Hunting dog Other Have you owned a pet before? NO YES Cat, Dog or both What breed? How long did you have the pet? If you no longer have your pet, what happened to it? Do you currently have any pets? YES NO If yes, how many of each? Dogs: # Cats: # Other: # Are all of your pets up to date on vaccinations? YES NO If not, please explain why: Are all of your pets spayed and neutered? YES NO If not, please explain why: Name of Veterinary Clinic: Clinic s Address: May we contact this vet as a reference? YES NO Page 1 of 4 (Rev. 5/14)
In what type of housing do you live? Your owned home A rented home A rented apartment A townhouse Live with parents Other Is your home in town or in the country? Is this dog specifically for your household? How long have you lived at your current residence? Do you plan to move within the next six months? YES NO Within the next year? YES NO How many people live in your household? Adults Children Ages Do children visit your home? YES NO What are the ages of the children visiting your home? Do all adults in your home have knowledge of and agree with your intentions to adopt this dog? YES NO Does anyone in your home have allergies to dogs? YES NO If yes, how will this be managed? On the following scale, please rate your home and lifestyle? 1 2 3 4 5 6 7 8 9 10 Quiet Grand As a Central Library Station Who would be responsible for this dog s primary and financial care? Estimate the cost for caring for this pet for one year: Food Vet Supplies Where will this dog be housed days? In my home Outdoors Other Where will this dog be housed nights? Indoors Outdoors Other How will the dog be kept while outside? Fenced yard Leash Kennel Tie-Out Other What type of protection will this dog have from weather while outside? How long of an adjustment period are you willing to give this dog from the time of the adoption? Two Weeks One Month 2-3 Months 3 + Months Page 2 of 4 (Rev. 5/14)
How many hours a day on average will this dog be alone in your home? 0-4 Hours 8-12 Hours 4-8 Hours 12 or more Hours Under what circumstances would you feel you could no longer keep the dog? Medical Reasons Too Active Too Protective Not Enough Time Too Expensive Destructive Too Noisy Aggression Relocation Other What would you do if you could no longer keep this dog? Please explain Would you like information on any of the following topics? House training Chewing Introducing dogs to cats Introducing two dogs Separation Anxiety Dog training Other How did you hear about BENCHS? Family/Friends Website TV/ Radio Petfinder Facebook Other: This application is not binding and is not a guarantee of adoption. RRPS reserves the right to verify any and all information contained in this application. RRPS also reserves the right to deny any adoption that is determined not to be in the best interest of the animal or the applicant. A background check may be completed prior to finalizing the adoption. If you are approved for an adoption, you will receive a phone call notifying you of the approval. Applicants that are not approved for adoption will receive an email notification. If you do not provide a valid email address you may not receive any notification. APPLICANT S SIGNATURE: DATE: Page 3 of 4 (Rev. 5/14)
FOR STAFF/ OFFICE USE ONLY ADOPTION STAFF INITIALS: STAFF COMMENTS: APPROVED APPROVED BY: NOT APPROVED PHOTOCOPY ID HERE Page 4 of 4 (Rev. 5/14)