HART Hoopeston Animal Rescue Team

901 West Main Street Hoopeston, Illinois 60942 - HART Hoopeston Animal Rescue Team 901 West Main Street Hoopeston, IL. 60942 217 283 0779 Fax 217 283 7963 DOG ADOPTION QUESTIONNAIRE It is our policy to make certain that each person who adopts a dog is aware of the responsibilities of pet guardianship, and is capable of and willing to accept those responsibilities morally, physically and financially. Not every person who desires to adopt a dog should do so. By completing this questionnaire, you will aid us in determining if you and your family are indeed ready for pet guardianship and if the dog of your interest would suit you and your lifestyle. Should you agree that adopting a pet is a commitment throughout the lifetime of your companion animal, please fill out this questionnaire. Be aware that completing this questionnaire and turning it in is no guarantee of approval for adoption. Please answer all of the questions truthfully and thoroughly, leaving questions blanks may eliminate or delay the application process. We will need a copy of your driver s license to perform a background check, please make sure that your driver s license and address match. * * * * * * * * * * * * * * * Dog(s) of Interest: PERSONAL INFORMATION Date: Name: Age: Name of spouse partner roommate: Street Address: City: State: Zip Code: If less than two years at address please provide previous address Does your driver s license reflect your current address, if not explain why Home Phone: Work Phone: Cell Phone: Email: Face book name pg. 1 updated: January 5, 2016

Occupation Title, Address & Phone: How long on job Spouse Occupation, Title, Address & Phone : How long on job Work Schedule: Spouse Schedule: Names of all persons living in your household, their relationship to you and ages: Please list two personal references: (Other than Family Members) Name: Relationship: Phone: Name: Relationship: Phone: YOUR HOME Type of dwelling? House Apt Condo Other Own Rent? If condo, what are the association s rules about pets? Are you familiar with your town s pet s ordinances? Are your animals tagged according to your town s ordinances? If not, why? Is your home on a busy street? Do you live in a high crime area Your home has: One story Two stories If you have a yard: Fenced (height: inches) Unfenced Does your home have a swimming pool? Yes No Is Your Pool in or above ground Is the pool fenced? Yes No How do you introduce a dog to a pool? Would you allow an inspection of your home by a rescue volunteer? Yes No If you do not own your home, do you have the landlord s permission to have a dog? Yes No Will you provide a letter from your landlord, on letterhead, giving permission to have a dog? Yes No Landlord s Name: Phone: pg. 2 updated: January 5, 2016

YOUR COMPANION ANIMALS Do you presently have a dog? Yes No Have you previously had a dog? Yes No If you presently have or had dogs in the past, please complete the charts below. In the column what happened, write: gave away, sold him/her, took to the pound, abandoned, died, etc. (If the dog died, please state the cause of death.) CURRENT DOG(S) ****** Is your dog currently on Heart Worm Preventative? Yes No Were your previous dogs on heartworm prevention Yes No If yes what kind of prevention does your dog receive Where do you purchase your heartworm prevention, Vet Other Does your dog receive routine annual heartworm testing If your dog is NOT on heartworm prevention please explain why _ Name & Breed Age Sex Spay/Neutered? How & Why Obtained? How Long? PREVIOUS DOG(S) Name & Breed Age Sex Spay/Neutered? Kept In/Out What Happened? Year Have any of your dogs ever had puppies? Yes No If yes, do you breed for: Fun Profit Show Accident Has any member of your family ever experienced animal-related allergies? Yes No Have you ever trained a dog in obedience classes? Yes No Have you ever trained a dog: Basic Commands Herd Hunt Guard/Attack Other If you have other pets, please complete the following: Name & Species How Many? Ages Kept Where? Since what year? If cat, de-clawed? Your family veterinarian(s): (Under what First & Last Name and Pet s Name Used) Name: Phone: pg. 3 updated: January 5, 2016

YOUR NEW DOG Who would be responsible for the care of the dog? What is your primary reason for adopting a dog? Companion Guard dog Hunting Attack dog Working (herding) Other If Companion, whose? You Spouse Children Other pet Someone else (who?) Where will the dog sleep? Inside (where? ) Outside (where? ) How many hours per day will the dog be left alone? How many minutes & or hours will the dog be left unattended inside How many minutes & hours will the dog be left unattended outside Where will the dog be left when he/she is alone? Indoors Outdoors If outdoors: Yard Patio Kennel Garage Other If yard: Do you have a doggie door? Yes No Do you intend on crating your new dog, if so how long of a time If your home does not have a fence how do you plan on taking your dog out for bathroom breaks, On leash, off leash, teaching boundaries? Please explain, Do you intend to hire a dog-sitter or take the dog to a daycare center? Yes No When you are at home, the dog would be: Indoors Outdoors Other Which rooms or areas of the home/yard will be off-limits to the dog? How will you socialize your new dog Do you allow dogs on furniture? Yes No Some (which? ) If the dog will be outside at all, what outside space is available for the dog: Yard Patio Dog Run Balcony Unfenced yard Other Are the gates: Latched Padlocked Other How do you plan to handle the dog s exercise needs? Do you feel obedience training makes a dog a better companion? Yes No If necessary, would you be willing to attend obedience classes at your own expense? Yes No Do you travel a great deal? Yes No How often? How long at a time? When you travel, how do you intend to provide for the dog while you are gone? What are your beliefs on spaying and neutering? What provisions would be made for the dog if you had to move: Locally Out of state pg. 4 updated: January 5, 2016

To a place where no pets are allowed? Under what circumstances would you not keep the dog? Divorce Illness in family Moving New baby New job Housetraining problems Chewing Barking Digging Allergy Shedding too much Dog grew too big Dog becoming ill Kids ignore the dog Pets didn t get along Not obedient enough Other (explain ) Would not give up for any of above reasons What would you do if the dog grows to be bigger than you expected? Return dog to rescue Take dog to shelter Keep but keep outside Other If the dog becomes destructive at your home, what would you do? If the dog has accidents at your home, what would you do? If the dog shows Separation Anxiety, what would you do? If the dog becomes aggressive to people and/or other dogs, what would you do? * People Aggression: * Other dog aggression: If the dog becomes ill or injured, are you financially prepared to provide the medical care? Yes No If yes, is there a maximum amount you would spend for your dog s medical needs? Yes $ Reason? No State provision: The dog may live 15+ years. What would you do with your dog if you could no longer care for them? Is there anything else you would like to tell us about yourself? * * * * * * * * * * * * * * Questionnaire Information: All the information I have provided in this Questionnaire is true and accurate to the best of my knowledge. If any of the information changes, I will advise you promptly. Signature: Date: Print Name: pg. 5 updated: January 5, 2016

***PLEASE ALLOW 7 DAYS FOR THOROUGH PROCESSING OF APPLICATIONS. APPLICATIONS ARE APPROVED BASED ON BEST MATCH, NOT FIRST COME-FIRST SERVE. THANK YOU FOR YOUR PATIENCE AND UNDERSTANDING. ***Please review your application to ensure that it is filled out accurately and honestly. An incomplete application will NOT be reviewed. Dis-honesty will automatically null and void any adoption of an animal. *** No person will be allowed to adopt any animal that has a criminal background, charges or convictions. pg. 6 updated: January 5, 2016