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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. Dog(s) of Interest
8. First Name*
9. Last Name*
11. Your Address*
13. Your City*
14. Your State*
15. Zip Code*
17. Your Phone Number*
18. Your Email Address*
20. How long have you lived at this address?*
21. Are you 18 or older?*
    -- Select One --YesNo
22. Do you plan to move in the near future?*
    -- Select One --YesNo
24. Reason your adopting today?*
    -- Select One --Companion for dog/catCompanion for myselfFor my parentsAs a gift
25. Living Situation*
    -- Select One --Rent House /ApartmentOwnLive with parentsMobile home or Condo
26. Landlords name and phone number
28. Social Environment

    1. Active home with frequent visitors
    2. Quiet home with few visitors
    3. Quiet home with frequent visitors
    4. Dogs/Cats visit
    5. Children visit often:
    6. Dog will travel with me daily
29. Ages of children?
30. How many adults live in the home?*
32. Children in Home?*

    1. Yes
    2. No (under 20)
33. Ages of children in home
34. How do you exercise your pet?*
    -- Select One --Leash walk onlyFenced yard/Leash walkFenced yard only Dog ParkDoggie DaycareAgility/Obedience ClassHike OftenDaily play sessionsLeave in yard during dayPlay dates with other dogs Doggie door
35. How many hours will the dog be left alone?*
37. When alone, the dog will be*
    -- Select One --CratedLoose in houseBaby gated in a roomKept outsideKept in basement/garagePut into a closed door room
38. Where will dog sleep at night?*
    -- Select One --Dog BedCrateMy BedBasement/GarageOutside/Dog HouseLoose in House
39. Will you train your dog?
    -- Select One --Train myselfObedience TrainerCrate TrainWant already trained dog
41. Fence Information
43. fence*

    1. Not fenced
    2. Yard partially fenced
    3. Yard completely fenced
44. Height of fence*
45. Type of Fence

    1. Stockade
    2. Chainlink
    3. PVC
    4. Post/Rail
    5. Chicken wire
47. What behavior(s) do you desire or could accept? (check all that apply)*

    1. Very Active/Active
    2. Mildly Active
    3. Couch Potato
    4. Well Mannered
    5. Reserved/Shy
    6. Walks gently on leash

    1. Playful
    2. Pushy/Tests the limits
    3. Protective of the family/Home
    4. Clingy/Dependent
    5. Dog Friendly
    6. Cat Friendly
49. Do you presently have a pet? If so what are the breeds, age, sex, altered, and for how long have you had them?*
51. 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?*
53. Preferences
    -- Select One --MaleFemaleBoth
54. Age
55. Size preference
    -- Select One --Under 25lbs25-50 lbs50lbs & aboveNo preference
57. Your Family Veterinarian Name and Phone Number*
58. Last name under which records would be? *
60. Do you plan on getting another pet in the next 6 mos? Y/N If yes, what type and when *
62. Have you ever had to rehome a pet? If so why?*
64. References
66. Family Personal Reference ( Name, phone number and relationship)
68. Non Family Personal Reference ( Name, phone number and relationship)
70. I hereby certify that all information is true, accurate and complete.
72. 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.
74. Electronic Signature*
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit Submit and Print

* indicates a required field