Adoption Application

Dog Information
Name of Dog*
Age of Dog*
Why do you believe the pet for whom you are applying would be a good match for your household?*

Contact Information
Applicant's Name*
First Last
Date of Birth*
MM slash DD slash YYYY

Please note: if you are over the age of seventy and wish to apply for a dog under the age of 3, you must have an approved co-applicant who can take over the care of the dog in the event it is needed
Cell Phone*
Home Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Co-Applicant's Name
First Last
Date of Birth
MM slash DD slash YYYY

Please note: if you are over the age of seventy and wish to apply for a dog under the age of 3, you must have an approved co-applicant who can take over the care of the dog in the event it is needed
Cell Phone
Home Phone
Email
Ages of children living full-time with you
Please note: CDHA will not adopt to families with children under the age of five years old)
Ages of children who frequently visit
Do they have familiarity with dogs? Explain

Employment
Company Name
Type of Employment
- Full Time
- Part Time
How long have you worked here
Subject for relocation?
- Yes
- No
What is your work schedule like?*
CDHA requires adopters of dogs under one year of age to have a flexible work schedule so the dog will not be left alone for more than three hours a day
If a dog will be left alone for more than five hours while you are at work, what is your plan for getting him or her necessary walks and human interaction during the day?

Pet History
Are you currently the guardian of any animal full-time?*
- Yes
- No
List ages and breed information and if they are spayed or neutered
Age Breed Spayed / Neutered?
If no, how long has it been since you have had a cat or a dog?
Name of veterinarian’s practice
You must call this veterinarian before handing in this application to give authorization for a CDHA representative to call for vaccine history
Phone
How long have you been a client?
Name(s) of pet(s)
Have you ever had a dog or cat die prematurely?*
- Yes
- No
If yes, please explain
Were all previous pets spayed/neutered?
- Yes
- No
If no, please explain
Have you ever given away a pet?*
- Yes
- No
If yes, please explain
If you are applying for a long-haired dog, are you aware of the grooming needs and costs for the animal?
- Yes
- No
Groomer Reference
Phone

CDHA Adoption Applicant:

Thank you for taking the time to complete this questionnaire. Completion of his application does not entitle the applicant to adopt a dog. By submitting this document, the applicant is attesting to the truthfulness of the answers. Falsified or incomplete information will be grounds to disallow adoption or reclaiming of a CDHA pet that has already been placed.
Signature*
I attesting to the truthfulness of the answers on this application
Applicant's Name
Co-applicant’s Name
CAPTCHA

Dog Information

Age	Breed	Spayed / Neutered?