THE HUMANE SOCIETY
2 JACKSON STREET
BINGHAMTON, NY 13903
  

ADOPTION REQUEST

DOGS
  
  DATE: _____________________________________ I.D. TAG: ___________________________________
  DOG'S NAME: ______________________________ SHELTER ID: _______________________________
  BREED: ____________________________________ DOG LICENSE: ______________________________
  AGE: _______________________________________ FR. DESK INITIALS: _________________________
  TECH INITIALS: _____________________________ COLOR: ____________________________________
  RABIES DATE: ______________________________ SPAYED/NEUTERED: ________________________
  ADMIT DATE: ______________________________ FEMALE/MALE: _____________________________
   
  1.    NAME: ______________________________________________________________________________
  2.    NAME OF SPOUSE/ROOMATE(S): _______________________________________________________
  3.    NUMBER OF PEOPLE IN HOME: ADULTS_________CHILDREN_____________
             AGES OF CHILDREN _________________________
  4.    IS ANYONE IN THE HOUSE ALLERGIC TO ANIMALS? YES_______ NO_______
         If yes, who? ________________________ To what? ___________________________________________
  5.    OCCUPATIONS: _______________________________________________________________________
  6.    COMPLETE PHYSICAL ADDRESS: (Street:)________________________________________________
    (City:)___________________________________(State:)___________________(Zip:)_________________
7.    COMPLETE MAILING ADDRESS (if different): (Street:)_______________________________________
       (City:)___________________________________(State:)___________________(Zip:)_________________
8.    TELEPHONE: HOME (______)___________________   WORK (______) ____________________
9.    TYPE OF DWELLING: HOUSE / CONDO / APT / OTHER ____________ (circle one)
10.    DO YOU RENT? ______ OWN? _______
11.    LANDLORD'S NAME ________________________________ PHONE (______)_________________
12.    IS ANY ADULT HOME DURING THE DAY? YES _____ NO _____
13.    HOW MANY HOURS A DAY WILL THE DOG BE LEFT ALONE? _____________________________
14.    ARE YOU LOOKING FOR AN INDOOR ______ OUTDOOR ______ OR BOTH _______
15.    WHERE WOULD THE DOG BE WHEN YOU'RE NOT AT HOME?
     _______________________________________________________________________________________
16.    WHERE WILL THE DOG SLEEP? ________________________________________________________
17.    WHAT OUTSIDE SPACE IS AVAILABLE TO THE DOG? ____________________________________
     ______________________________________________________________________________________
18.    DO YOU OWN A PET NOW? YES_______ NO _______  IF YES, PLEASE LIST:
     ______________________________________________________________________________________
     ______________________________________________________________________________________
     ______________________________________________________________________________________
19.    HAVE YOU HAD PETS IN THE PAST? YES_______ NO _______  IF YES, PLEASE LIST:
     ______________________________________________________________________________________
     ______________________________________________________________________________________
20.    ARE THEY CURRENT ON THEIR VACCINATIONS? YES_______ NO_______
21.    WHO IS YOUR VETERINARIAN? ______________________________________________________
22.    HOW MUCH TIME ARE YOU WILLING TO SPEND ADJUSTING TO AND HELPING THIS ANIMAL ADJUST TO YOUR HOME AND LIFESTYLE?
     ______________________________________________________________________________________
23.    UNDER WHAT CIRCUMSTANCES WOULD YOU NOT KEEP THIS DOG?
    ______________________________________________________________________________________
24.    WHAT DO YOU FEEL IS AGGRESSIVE BEHAVIOR?
    ______________________________________________________________________________________
25.    WHAT WOULD YOU DO IF THIS OCCURRED?
    ______________________________________________________________________________________
26.    HAVE YOU PREVIOUSLY ATTENDED A BASIC OBEDIENCE COURSE WITH YOUR DOG(S)?
       YES_____NO_____ WHY OR WHY NOT?______________________________________________
27.    DO YOU PLAN TO COMPLETE A COURSE WITH THIS DOG(S)?
    ___________________________________________________________________________________
28.    WOULD YOU OBJECT TO AN INSPECTION OF YOUR HOME? YES______ NO______
29.    HOW WILL THE DOG BE EXERCISED?
    _____________________________________________________________________________________
    _____________________________________________________________________________________

 
I certify that the above is true and correct.  Any false information may result in the nullification of this adoption.
    
SIGNATURE ____________________________________________ DATE ______________________