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2. Animal Shelter and Adoption Center Matchmaker Application

4. Important Note
   It is our policy to make certain that each person who adopts a dog is aware of the responsibility abilities of pet guardianship and is capable of and willing to accept those responsibilities morally, physically, and financially.
   
   ****We reserve the right to determine which home would be best suited for each one of our animals. ****
   
   By completing this questionnaire, you will aid us in determining if you and your family are indeed ready for pet guardianship, and if the dog of your interest would suit you and your lifestyle.
   
   Should you agree that adopting a pet is a commitment throughout the lifetime of your companion animal, please fill out this questionnaire.
6. Are you Interested in seeing our DOGS or CATS?*

   1. Dogs

   1. Cats
8. Dog(s)/Cat(s) of Interest
10. First Name*
11. Last Name*
13. Your Address*
15. Your City*
16. Your State*
17. Zip Code*
19. Your Phone Number*
20. Your Email Address*
22. Are you 18 or older?*
    -- Select One --YesNo
23. How long have you lived at this address?*
24. Do you plan to move in the near future?*
    -- Select One --YesNo
26. Reason your adopting today?*
    -- Select One --Companion for dog/catCompanion for myselfFor my childrenFor a senior
27. Living Situation*
    -- Select One --Rent. What is the pet policy?OwnLive with parentsHouse ApartmentMobile home or Condo
28. Will you train your dog?
    -- Select One --I want an already trained dogI've always trained myselfI'll go to trainer/class
30. Social Dynamtic*
    -- Select One --Quiet homeLively home with kids and/or other petsPet will travel with me daily Few people in home but we're pretty social, friends around often
31. You and your household/Animal Experience*
    -- Select One --First time ownerHave had one or twoHave had manyHave attended training class/hired
32. How do you exercise your pet?*
    -- Select One --SportsDog parkPlay with him in the yardWalksHikesPlay in yard with other dogDoggie DaycareTraining ClassesPlay insideother
34. Do you have children? If so what ages?*
35. Do children visit the home often? If so what ages?*
36. Do you have a yard?*
    -- Select One --YesNo
38. Do you have a fence? How high and what type of fence?*
39. How long will the dog be left alone in the yard?
41. During the Day my dog will be
    -- Select One --OutsideInsideOutside and garageUses dog doorCrate/Kennel
42. At night my dog will be
    -- Select One --OutsideIn the garageInside
43. During the day my cat will be
    -- Select One --indoorsIn/outOutdoors
45. Do you presently have a pet? If so what are the breeds, age, sex, altered, and for how long have you had them?*
47. Have you previously had a pet? If so what were the breeds, age, were they kept in or outside and for how long have you had them?*
49. Have you ever had to rehome a pet? If so why?*
51. Do you plan on getting another pet in the future? What type?*
53. Preferences
    -- Select One --MaleFemale
54. Age
55. Size when full grown
57. What behavior(s) do you desire or could accept?

    1. Very Active/Active
    2. Calm/Gentle/Well Mannered
    3. Reserved/Shy
    4. Confident
    5. Playful

    1. Pushy/Tests the limits
    2. Protective of the family/Home
    3. Clingy/Dependent
    4. Dog Friendly
    5. Cat Friendly
59. Are you open to rescuing a Special Needs Pet?*

    1. Yes
    2. No
61. Specialties
    Medical, will require continued veterinary care
    
    Behavioral; that will require additional professional help
    o Guarding issues
    o Fearfulness
    o Severe Separation Anxiety
    o Stranger Weary
    o Socially Restricted pet
    o Very strict, not good with other animals
    
63. Your Family Veterinarian Name and Phone Number
65. I hereby certify that all information is true, accurate and complete.
67. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
69. Electronic Signature*
Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit Submit and Print

* indicates a required field