Dog Pre-Adoption Application (rev 3-10-16) 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. Name of the dog you would like to adopt: ( ) Name: Address: City/State/ZIP Date: E-Mail Address: Primary Phone #: Have you owned a pet before? YES NO How long did you have the pet? If you no longer have your pet, what happened to it? Have you surrendered a dog in the past 5 years? Do you currently have any pets? 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 Why would you like to adopt this dog? Companion for me and my family Therapy dog
Companion for my other pets Watchdog/Farm dog Hunting dog Other In what type of housing do you live in? Own your home A townhouse Other A rented home Live with parents A rented apartment On a farm How long have you lived at your current residence? Do you plan to move within the next six months? YES NO Within the next one year? YES How many people live in your home? 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 Does anyone in your home have allergies to dogs? YES 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 to care for this dog for one year: Vet Supplies Estimate the cost to feed your food per month: Food Where will this dog be housed? In my home Outdoors Other How will the dog be kept while outside? What type of protection will this dog have from weather while outside? How long 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
How many hours a day on average will this dog be alone in your home? 0-4 Hours 4-8 Hours 8-12 Hours 12 or more Hours Under what circumstances would you feel you could no longer keep the dog? Medical Reasons Destructive Too Active Too Protective Not Enough Time Too Noisy Aggression Relocation Too Expensive 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 BENCHS has access to criminal history records. Have you or a significant other been convicted of a gross misdemeanor or a felony in the past 5 years? How did you hear about BENCHS? Family/Friends Website TV/ Radio Petfinder Facebook Other: 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:
FOR STAFF/ OFFICE USE ONLY ADOPTION STAFF INITIALS: STAFF COMMENTS: APPROVED APPROVED BY: NOT APPROVED PHOTOCOPY ID HERE