Pre-Adoption Questionnaire

Name:___________________________________________________

Home Phone:_____________ 
Work Phone:______________

Address__________________________________________________

Mailing Address (if different)_________________________________

State:______Zip:___________________

Email:___________________________________________________

Occupation:_______________________________________________

Place of Employment________________________________________

Household

Spouse/Partner____________________________________________

Employment/Occupation_____________________________________

Work Phone_________________

(Circle the correct answer)

Home is:   house    condo    mobile home    apartment

Do you:    rent     own    lease    lease with option to buy

Do you live with:  parents   Spouse/partner   Roomate(s)

                         Children     Alone

Please list the names of all household members. Indicate ages if under 18.

Name:_______________________Age_______Name:_______________________Age_______

Name:_______________________Age_______Name:_______________________Age_______

Do you have cats?  Yes   No   Age(s)________

Do you have birds?

For whom are you adopting this pet? _________________

Do any household members have allergies?____________

Who will be primarily responsible for the care & supervision of this pet?_______________________________

Long Term Pet Care

Are you prepared to care for this dog for its lifetime (10-15 years)?
   Yes   No

Are you prepared to take this dog with you if you move?   Yes   No

Are you prepared to pay for and keep you pet’s vaccinations current?
   Yes   No

Are you prepared to seek veterinary care if the pet is sick or injured?
   Yes   No

How will you care for this dog when you go on vacation or have an
emergency?


Animal Selection
 

What type of dog do you prefer?    Active      Less-Active
  Breed(s)

What exercise will you provide for this dog?

Are you interested in doing obedience or agility with your dog?
  Yes   No   

How many hours each day will your dog be WITHOUT human companionship?________________________
 

Have you ever housetrained a dog before?   Yes   No
Have you ever crate trained a dog before?    Yes  No

What are your leisure time activities?

Please list the pets that you have had in the past 5 years

Breed/Type Age Sex Spayed/Neutered

How long owned? What happened to the pet?

As a puppy, where will this pet be kept when you are home?

When left alone?

At night?

Do you have confinement outdoors for this dog? Yes No
What type?

Who is your Veterinarian? Name_______________________________
Phone No.________________________
 

Please provide 2 references (no relatives)

Name:________________________________Phone_______________

Name:________________________________Phone_______________
 

Adoption Agreement:
I CERTIFY THAT THE ABOVE IS TRUE AND UNDERSTAND THAT FALSE INFORMATION MAY RESULT IN NULLIFYING THIS ADOPTION.

PETS ADOPTED FROM THE KETCHIKAN HUMANE SOCIETY MUST BE RETURNED IF ADOPTING OWNER CAN NO LONGER CARE FOR THEM.

ALL PETS WILL BE SPAYED/NEUTERED AND VACCINATED IN ACCORDANCE WITH ADVICE FROM A VETERINARIAN. DOGS WILL BE LICENSED BY THEIR MUNICIPALITY.

I UNDERSTAND THAT THIS QUESTIONNAIRE REMAINS THE PROPERTY OF THE HUMANE SOCIETY
 

Signed_______________________________Date_______________
 

Printed Name_____________________________________________