HOW DID YOU HEAR ABOUT PET ORPHANS OF SOUTHERN CALIFORNIA?     

Name of Dog(s)
Minimum Donation*
Date

*The donation covers the cost of DHLPP & Bordatella, Rabies, Deworming, Flea Control, Spay/Neuter, Tracking Tag for 24 hour Lost & Found Service, Microchip, Leash & Martingale Training Collar, Canidae Dog Food, "Urban Puppy Tool Kit" and Training & Acclimation DVD

If you can increase the donation fee for the dog you are adopting, please do so, if you cannot, please remember us during the holiday gift giving season and for donations of dog and cat toys, cat beds, old blankets and towels and other items all rescue groups need. But most importantly PLEASE remember to tell your friends who FALL IN LOVE with your dog (because they will) to ADOPT, don't breed or buy.

APPLICANT INFORMATION

Firstname      Lastname

Occupation

Address

City       State       Zip

Home Phone       Work Phone

Cell Phone      E-Mail

Number of Persons in Household
    Relationships

Number of Children       Ages of Children

Name of Spouse/Roommate
Occupation of Spouse/Roommate

RESIDENCE INFORMATION

Do you agree to a home & yard safety inspection?    Yes    No

Do you rent or own?       Type of Dwelling?

If you rent, does your lease allow you to own pets?   Yes   No

Landlord's Name       Landlord's Phone Number

Type of fencing in front yard
   Highest height       Lowest height

Type of fencing in back yard
   Highest height       Lowest height

Number of gate(s)    Type of gate(s)    Height of gate(s)
Are your gates secured?    Yes    No      If yes, how?

Who, other than members of your household, has access to your yard when you are not at home (i.e. gardner, poolman, meter reader, relative, etc.)?
Where would the dog(s) be when these persons have access?

Do you have a swimming pool?    Yes    No
   If yes, Is it fenced in?    Yes    No
  Do you know how to introduce a dog to a swimming pool?    Yes    No

AREAS AVAILABLE TO YOUR DOG(S)

At what times would the dog be inside?  Outside?

What areas of the house would the dog be allowed?
What areas of the house would be off-limits to the dog?

Where would the dog stay when he/she is home alone?

About how many hours a day would the dog be home alone?
About how many hours a day do you anticipate someone spending with the dog?

What outside areas are available for the dog?
Backyard     Front Yard     Balcony    Kennel/Run    Covered Patio
   Garage    Other

Do you have a pet door?   Yes   No
If not, would you be willing/able to install a pet door?   Yes    No

Where will the dog sleep at night?   Dog house     Inside     Garage
    Other
If inside, where exactly?   Kitchen     Bedroom w/family member
    Spare bedroom     Laundry room    Run of the house
    Other
Additional comments on where the dog will sleep


Will the dog be allowed on furniture?   Yes  No

Do you intend to take the dog to an off-leash dog park?   Yes   No

PRESENT AND PAST COMPANION ANIMAL INFORMATION

Do you presently have a companion animal?   Yes   No
Have you previously had a companion animal?   Yes    No

If you now have or have had companion animals in the past, please complete the sections below. In the column "what happened" please indicate if still have, lost, stolen, sold, given away, taken to shelter, found a new home for, died, etc. (if the animal died, please state cause of death).

1. Breed/Species      Age      Sex      Altered? (Y/N)
  Indoor or Outdoor Pet?
Dates Owned / How Acquired?
Where is pet now?

2. Breed/Species      Age      Sex      Altered? (Y/N)
  Indoor or Outdoor Pet?
Dates Owned / How Acquired?
Where is pet now?

3. Breed/Species      Age      Sex      Altered? (Y/N)   Indoor or Outdoor Pet?
Dates Owned / How Acquired?
Where is pet now?

4. Breed/Species      Age      Sex      Altered? (Y/N)   Indoor or Outdoor Pet?
Dates Owned / How Acquired?
Where is pet now?

Have any of your animals ever had a litter?   Yes    No
If yes, did you breed for?   Fun    Profit    Show    Accident
Other

Is breeding an animal something you would consider in the future?   Yes    No
If yes, why?

Have you ever had to give up a pet?   Yes    No
If yes, please explain circumstances:

Does any member of your household suffer from animal related allergies?   Yes    No
If yes, how do you intend to deal with this?

What is your primary reasons for adopting a dog?
Companion for you      For your kids      For other pet      Gift      Watch Dog

Who would be responsible for the care of your new dog?

Preferred level of exercise with dog? (choose all that apply)
Couch potato     Yard exercise     Short walks     Vigorous walks
   Hiking/Jogging

How would you rate your dog experience?
1st time owner    Beginner    Intermediate    Advanced

How would you normally walk your dog?   On leash    Off leash
When on leash do you normally use:   Collar    Choke chain    Harness
   Other

Do you have any experience in obedience training?   Yes    No
If yes, please explain

Would you be willing to attend obedience training at your own expense? Yes No

How would you encourage your dog’s appropriate behavior?
How would you correct your dog’s undesirable behavior?
What would you do if the undesirable behavior continued?
Have you ever had to handle an animal’s continued undesirable behavior?   Yes   No
If yes, please explain

Do you know how to housebreak a dog?  Yes  No
What would you do if you had difficulty in housebreaking your dog?

What would you do if the dog became destructive in your home?

Are you able to make a lifetime commitment to care for your pet
including medical care, grooming, proper diet, shelter, exercise and love?   Yes    No

Are you prepared for veterinary expenses, including emergency
medical costs that will be incurred when adopting this dog for its’ entire life?   Yes   No

Have you ever had an animal with severe medical expenses?   Yes    No
What did you do in these circumstances?

Do you travel a great deal of the time?   Yes    No
What provisions will you make for the dog’s care when you travel ?


How would you go about locating your dog if he/she became lost?


Do you plan on using ID for your pet ?   Yes   No      If yes, what type?

If unforeseen circumstances caused you to vacate your premises and
you had trouble finding a place to live that allowed pets, what would you do?


If something were to happen to you and you were no longer able to care for your dog, what would you do?

Which of the following reasons might prompt you to give up your pet? (check all that apply)

Do you plan on having any or more children in the future?
(Some dogs due to temperament would not be appropriate for a home with children, due to our commitment to making responsible placements of our animals we ask that you consider this question seriously.)
If you had to give up your dog, what would you do?

Do you currently have a veterinarian?   Yes    No
If yes, Name      and city

Would you like a referral to a veterinarian?   Yes     No

Why have you chosen this particular dog?


Is there anything else about yourself that you would like to share with us?

By clicking the "Submit button" you certify that the above is true, and that I realize that any false information given may result in nullifying the adoption.