Adoption ApplicationStep 1 of 616%Dog InformationName 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 InformationApplicant'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 neededCell Phone*Home Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 neededCell PhoneHome PhoneEmail Ages of children living full-time with youPlease note: CDHA will not adopt to families with children under the age of five years old)Ages of children who frequently visitDo they have familiarity with dogs? ExplainEmploymentCompany NameType of Employment Full Time Part TimeHow long have you worked hereSubject for relocation? Yes NoWhat 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 dayIf 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 HistoryAre you currently the guardian of any animal full-time?* Yes NoList ages and breed information and if they are spayed or neuteredAgeBreedSpayed / Neutered? If no, how long has it been since you have had a cat or a dog?Name of veterinarian’s practiceYou must call this veterinarian before handing in this application to give authorization for a CDHA representative to call for vaccine historyPhoneHow long have you been a client?Name(s) of pet(s) Have you ever had a dog or cat die prematurely?* Yes NoIf yes, please explainWere all previous pets spayed/neutered? Yes NoIf no, please explainHave you ever given away a pet?* Yes NoIf yes, please explainIf you are applying for a long-haired dog, are you aware of the grooming needs and costs for the animal? Yes NoGroomer ReferencePhoneHomeOwn or Rent* Own RentIf rent, landlord informationType of residence Ranch Mobile Home Two-Story Condo Townhome Apartment How long have you lived at this address?If less than one year, please provide former residence where you lived for more than a year.How long did you live there?Backyard Fence* Yes NoHeight and typeSecure on all sides?Approximate size? (area)If no fence, plan for exercising a dog?In-ground pool? Yes NoAware of Local Leash Laws? Yes NoYour household activity level? Quiet Moderate BusyYour neighbors household activity level? Quiet Moderate BusyWhere will pets be kept when you are not at home?Where will the pet be kept when you are at home?Will the dog be allowed to sleep on your bed and relax on your furniture?For what reason(s) would you consider relinquishing custody of a pet? Check all that apply Moving Nipping biting people Barks too much Housebreaking accidents Cost is more than expected Divorce or Separation from partner Dog has separation anxiety Nipping or biting other animals Destructive Family develops allergies New baby OtherIf Other, please explainCDHA 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 applicationApplicant's NameCo-applicant’s NameCAPTCHAΔ Facebook Twitter Google+ Pinterest reddit