Date: Type/Name of dog desired? Age of dog desired? What is the oldest dog you would consider adopting? Approximate weight as an adult? APPLICANT INFORMATION Name: Address, City, State, Zip: How long at your current residence? Home Phone: Date of birth: Cell Number: Employment status:
Employed Unemployed Retired Student If employed, list employer and title. How long at your current job? Work Number: Email Address: How many other adults live in your home? What are their ages? How many children live in your home? What are their ages? Does anyone living in the home have allergies
to pets? If yes, please explain. CO-APPLICANT INFORMATION Name: Relationship: Cell Number: Email Address: Date of birth: Employment status:
Employed Unemployed Retired Student If employed, list employer. Work Number: GENERAL INFORMATION Do you own or rent your home? If you own your home, can you provide a copy of your
title deed, tax statement, mortgage statement, etc, as proof? Can the Tax Assessor verify the name on the title of
property? If you own your own home, does your home owners insurance,
HOA, etc... have any restrictions on dogs such as quantity or breed? What county you live in? Do you plan on moving in the near future? What type of home do you live in? House Apartment Condo Mobile Home Farm/Barn If a rental, are dogs allowed? Are there any breed
restrictions? What are the size restrictions, if any? Complex name/address? Manager/Landlord name and phone number? Is your residence inside or outside the city limits? Type of Street Very busy road Slight traffic Residential area Country road What is the speed limit? Where will the dog live (not including walks and playtime)? Inside only Mostly inside Outside only Mostly outside Where will the dog spend nights? Inside Outside Do you have a securely fenced yard? If
so, what kind. Please be detailed. What is the height of your fence at the LOWEST point? Do you have an in-ground pool? Is it fenced
off or does it have a stable cover? Will you allow the dog to run loose? If
yes, where? How many hours per day will the dog be alone? Where will the dog stay when left alone? Describe the activity level in your home: Busy (visits by friends, meetings, children, parties
at home) Noisy (TV, stereo, machinery, tools, children playing,
dogs barking) Moderate (normal comings and goings) Quiet (homebodies, couch potatoes, very few guests) Other If you selected "other", please
specify. You may also use this section to add comments about the activity level in your home. In the absence of the primary caregiver, who will care
for the dog? Under what circumstances would you return the dog? New job Divorce New baby/pregnancy Move Dog became ill Other If you selected "other", please
specify. You may also use this section to add comments. If for some reason you are not able to
care for this pet in the upcoming future, what will you do with this adopted dog? Have you ever had to return or surrender
an animal in the past? If so, please list circumstances. Have you researched the breed(s) you are interested
in? Please explain the good and bad characteristics
of the breed. Are you willing and able to take responsibility if
this pet acquires an illness later in life? Are you willing and able to pay veterinary costs of
caring for your new pet? Are you willing and able to take the time to work with
the dog on various issues such as house training, chewing or other issues if they arise? If the dog is not house trained, how will you manage
this? Would you consider obedience training if required or
recommended? Please briefly tell us what type of methods
and/or tools you have used in the past when correcting a behavior. How much time are you prepared to allow for your new
pet to adjust to your home? Will you be able and willing to regularly exercise
this adopted dog? Please describe your method of exercise. PET INFORMATION Please list current pets names, species
and breed, age, sex, spayed/neutered, current on vaccines and if they are indoor or outdoor. If you currently have dogs, are they on heartworm prevenative
year round? If no, please explain. Please list past pets names, species and
breed, age at time of seperation, years owned, sex, spayed/neutered, current on vaccines and if they were indoor or outdoor.
If you had dogs, were they kept on heartworm preventative?
If no, please explain. Will your new dog be on heartworm prevention? Please list name and phone number of current vet. Please list the name and phone number
of past vets and/or other vets you have used. Do you consider your pets a part of the family? Are you aware that a dog is a large and lifelong committment? Are you willing and able to take care of this pet for
its natural lifetime? PERSONAL REFERENCES Please list two non-relatives, your relationship
to them, phone number and best time to contact. Is there anything else you would like
us to know about you that may help in approving your application? Comments? Questions? There are many ways you can help us. Some are as simple
as letting us register your Food Lion MVP Card. Please go back to the Home Page and click on Food Lion MVP Cards and Ways
You Can Help to find out more. You can also list your Food Lion MVP card number here in the space provided. Thank you so much
for helping us help dogs and people!
