Canine Connections of NC

Dog Adoption Application Form

Contact Information
Full name:

____________________________________________________________________

Occupation: ____________________________________________________________________
Address:

____________________________________________________________________

How long at this address: _________________________________________________________

Cell Phone: _____________________________________________________________________
Work Phone: __________________________________________________________________
Best time to call: _________________________________________________________________
Email address:

________________________________________________________________

Family & Housing

How many adults are there in your household and what is their relationship to you?
_________________________________________________________________________
How many children (ages)?
_________________________________________________________________________
What best describes your home? Single family house, town home, apartment, farm, etc?
_________________________________________________________________________
Please describe your household: __ Active __ Noisy __ Quiet __ Average
Do you own or rent? _____________________________________________________________
If you rent, please give the rules governing pets and the landlords name and number:
________________________________________________________________________________
(By providing this information you are allowing Canine Connection of NC to contact your
landlord, please inform them of this call so they will speak with us)
Do you live in a County, City or neighborhood/community that has ANY pet restrictions? Such
as number of pets allowed or any prohibited breeds. If so what are the restrictions?
________________________________________________________________________________

Does anyone in the family have a known allergy to dogs?

_____________________________

Is everyone in agreement with the decision to adopt a dog? _____________________________

Do you have time to provide adequate love and attention? _____________________________
Is the dog going to be a surprise or gift? If so for whom? _______________________________

Other Pets
What other pets do you have (specify type and number)? ________________________________
________________________________________________________________________________
Are these pets up to date on vaccines? _______________________________________________
Are these pets current on heartworm and flea/tick prevention? ___________________________
Are these pets spayed/neutered? If not, why? _________________________________________
________________________________________________________________________________
Have you ever surrendered a pet? If so, why? __________________________________________
________________________________________________________________________________
Have you ever had a pet euthanized? If so, why? _______________________________________
________________________________________________________________________________
Have you ever lost a pet to an accident? What happened? _______________________________
________________________________________________________________________________
How do you train and discipline your pets? ___________________________________________
________________________________________________________________________________

Veterinarian
Do you have a regular veterinarian?

__ Yes __ No

Veterinarians name: _______________________________________________________

Clinic Name:

_______________________________________________________

Clinic Address:

________________________________________________________

Clinic Phone:

________________________________________________________

(Providing Canine Connection of NC with this information you are allowing us to call your vet.
Please call your vet and ask them to authorize the release of information to Canine Connection
of NC.)

About the Dog You Wish to Adopt

What is your idea of an ideal dog and why?
Desired age: __________

Desired Size: _________________________________________

Desired breed: ___________________________________________________________________

Breed you would not adopt:________________________________________________________
Desired sex: _ Spayed Female _ Neutered Male _ No preference
Willing to adopt:

__ outgoing/hyper dog
__ shy dog
__ dog that needs regular medication __ dog that needs training
__ dog that needs grooming
__ None of these

Where will the dog spend the day? (describe) ___________________________________________

________________________________________________________________________________
Where will the dog spend the night? (describe) _________________________________________
________________________________________________________________________________
Number of hours (average) dog will spend alone daily? _________________________________
Who will have primary responsibility for this dog's daily care? ___________________________
Who will have financial responsibility for this dog? ____________________________________
What is your monthly budget for care of the dog? ______________________________________
Who will care for the dog in your absence (vacations/emergencies)? ______________________
Do you agree to provide regular health care by a Licensed Veterinarian? __ Yes __ No
Do you agree to keep the dog on monthly heartworm and flea/tick prevention? __ Yes __ No
Do you agree to keep the dog as an indoor dog? __Yes __No
Do you have a fenced yard? What kind of fence? If not, when the dog goes out how do you
plan to contain it?
________________________________________________________________________________
Do you agree to contact Canine Connection of NC if you can no longer keep this dog?
__Yes __No

Do you agree to return the dog to Canine Connection of NC if you can no longer keep it? __ Yes
__ No
Will you allow a representative of Canine Connection of NC visit your home by appointment?
__Yes __No
Would you be interested in fostering? __Yes

__No __Would like to know more

Personal References
Please list someone who is familiar with both you and your pets.
Name:
Address:
Phone:
Relationship (relative, neighbor, friend, etc.):
Name:
Address:
Phone:
Relationship (relative, neighbor, friend, etc.):
A dog can live for a long time 10, 15, even 20 years. During that time frame which of the
following would be a reasonable situation to cause you to give up your dog?
__ Moving to another state/country
__ Getting married or divorced
__ Having a baby
__ Chewing on furniture or possessions
__ Too expensive
__ Dogs health (arthritis/diabetes/cancer/etc)
__ Dog is elderly
__ Not housetrained
__ Moving into a new no pet apartment or house
__ Moving in with parents or friends
__ Children wont take care of dog
__ Dog doesnt like new puppy/kitten
__ Other: ____________________________________________
__ None of the above
Please use this space to share any additional information you feel is important:

All of the information I have given is true and complete. This dog will reside in my home as a
pet. I will provide it with quality dog food, plenty of fresh water, indoor shelter, affection,
annual physical examination, vaccinations as well as heartworm and flea/tick prevention
under the supervision of a licensed Veterinarian. If the dog I am adopting has not been spayed
or neutered, I agree to provide Canine Connection of NC with a copy of the spay/neuter
records within 30 days or, if a puppy, by the age of 6 months.
___________________________
(Signature)

_________
(Date)