Name*:
Home Phone*:
Cell Phone:
Dog or Puppy applying for by name:
Dog or Puppy applying for by P or D #:
Address*
Apt.#
City*:
State*:	AK AL AR AZ CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code*:
Employer:
Work Phone:
Email Address:
Best number to call you weekdays?	Home Work Cell

How did you hear about us?	Friend Web Newspaper Humane Society Drive-By Other
If Other chosen, please explain:
Would you like to find out more about volunteering, fostering, or socializing animals? Yes No
Have you ever had to turn an animal in to a shelter before?	Yes No
Have you ever applied to adopt an animal from the Humane Society of Forsyth County?* (Must choose one)	Yes No
Have you ever adopted an animal from the Humane Society of Forsyth County?* (Must choose one)	Yes No
If yes, who did you adopt?
Would you agree to a home visit from a Humane Society Volunteer as a condition of adoption?*(Must choose one)   Yes No
What's this about a home inspection?

Why do you want a dog?*:	Family Pet Gift Guard Dog Other
If Other chosen, please  explain: *
Will it be indoors, outdoors, or both?*	Indoors Outdoors Both
Where will he or she sleep?*
What percentage of time will the dog spend:	Outside? *  Inside? *
Who will be the primary adult responsible for training?*
Are all your current pets up to date on vaccines?	Yes No Some Are Does Not Apply, this is a gift Does Not Apply, this is my first animal Do Not Know
On Heartworm Preventative?	Yes No Some Are Does Not Apply, this is a gift Does Not Apply, this is my first animal Do Not Know
If so, what kind?
On Flea Preventative?	Yes No Some Are Does Not Apply, this is a gift Does Not Apply, this is my first animal Do Not Know
If so, what kind?
Please list all pets your family has owned in the past 5 years, including where they are now, Doctor that animal was seen by including Vet's phone number.
Do you give Humane Society of Forsyth County permission to contact vet? *
Pet 1: No other animals Cat Dog Bird Other
Where are they now?	Does not apply Still in current household Returned to original owner/shelter Deceased Ran Away Stolen Other
If other, please explain:
Veterinarian Clinic/Doctor:
Contact Information - phone:
Pet 2: No other animals Cat Dog Bird Other
Where are they now?	Does not apply Still in current household Returned to original owner/shelter Deceased Ran Away Stolen Other
If other, please explain:
Veterinarian Clinic/Doctor:
Contact Information - phone:
Pet 3: No other animals Cat Dog Bird Other
Where are they now?	Does not apply Still in current household Returned to original owner/shelter Deceased Ran Away Stolen Other
If other, please explain:
Veterinarian Clinic/Doctor:
Contact Information - phone:
More than 3? Yes No
If yes, you can provide Humane Society of Forsyth County (HSFC) more details later.
How much would you expect to spend yearly on routine vet visits, health care, and food for this pet?* $
(Expenditures include, annual vet checks and shots, healthy food, dental care, heartworm and flea preventative.)
Are you willing and able to make a commitment to do this routine vet/health care including heartworm and flea preventative every year?* Yes No Not Sure
Do you agree, for the pets safety, to keep an ID tag on this animal at all times?* Yes No Not Sure
The HSFC has provided one for each animal, or you may choose to purchase one with your information.
*If Outdoors: Is your yard fenced?	Yes No
If No, please explain how you will contain your new pet:
Do you have a pen or tie out?	None Pen Tie Out
What accommodations can you make for weather extremes?
How often will you check food and water?*
*If Indoors: Is your yard fenced?	Yes No
If No, how will he/she be taken out?
Have you ever housebroken a dog?	Yes No
Have you owned or lived with an indoor dog before?	Yes No
Have you ever "Crate Trained"?	Yes No
How many hours will the dog need to crated each workday?

If you know a member of the Humane Society of Forsyth County you would like us to contact for a personal reference, please use the space below.

Reference Name:
Relationship:	Friend Relative Neighbor Co-worker Other
If Other, please explain:
Reference Phone Number:
Reference Email:

If there is an animal care professional or other rescue organization you would like us to contact for a personal reference, please use the space below.

Reference Name:
Relationship:	Animal Care Professional Other Rescue Group
If Other Rescue, please give name of the rescue group:
Reference Phone Number:
Reference Email: