SAVING ANIMALS LIVES...THE HEART OF WHAT WE DO.

Help HEART place unadoptable rescue cats in safe, warm barn environments or warehouses.


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Adoption Application (Dog)


  *First Name *Last Name
  *Address
  *City *State   *Zip
  *Phone *Email
  *Age   (Must be 21 years of age or older)
*How many adults are in the home?
How many children?       Children's Ages?
If no children, are you expecting a child at present or planning to have children join your family in the future Yes   No
Is anyone residing in your home opposed to your adoption of a dog? Yes   No   Don't know
Does anyone in your household have an allergy to dogs?         Yes No
What type of home do you live in? Single Family   Apartment   Town House  Farm
Do you own or rent your home? Own   Rent
Briefly describe location of home on property and proximity to street?
Is your yard fenced in? Yes   No
Do you have a pool? Yes   No
Is there a chance you will be relocating in the near future? Yes   No
Do you have other pets?
Yes   No   If yes, what kind?
Are they current on vaccines? Yes   No
Are they spay/neutered?
Yes   No  If not, why?
Have you ever surrendered a pet to a shelter or given a pet away?
Yes   No If yes, what were the circumstances?  
Have you ever lost a pet to an accident? Yes   No
Have you ever had a pet euthanized?
Yes   No  If yes, what were the circumstances?
Do you have a regular Veterinarian? Yes   No
  Veterinarian's Name Phone
 (By providing HEART with this information, you are allowing HEART to contact your Veterinarian as a reference. Please contact your vet and ask them to authorize the release of information to HEART)
Have you already seen a HEART dog that you are interested in adopting?
Yes   No   If yes, who?   Where did you see this dog
Who will have primary responsibility for the dog's daily care?    
Do you agree to keep the dog as an indoor dog? Yes   No
Where will the dog be kept when home alone?  
What is the average number of hours the dog will be alone each day? 
How will the dog be supervised when outdoors?  
Do you agree to regular health care by a Licensed Veterinarian? Yes   No
Are you willing to let HEART representative visit your home by appointment? Yes   No
Are you willing to take responsibility for this dog for the next 10 to 20 years? Yes   No
*I certify that I have read this questionnaire and that the information I have given is true and accurate, and I understand that any falsification may result in the nullification of this adoption.

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