H.A.L.T. Helping Animals Live Tomorrow Dog Adoption Application Welcome to the H.A.L.T (Helping Animals Live Tomorrow) Adoption Program. The following information is requested so that we can assist you in the selection of a new dog. This form and a consultation with a H.A.L.T. representative are designed to help you find the dog most compatible with your lifestyle. In order to be considered as an adopter you must: * Be 21 years of age or older. * Have identification showing your present address. * Have the knowledge and consent of your landlord. * Be able and willing to spend the time and money necessary to provide training, medical treatment and proper care for a pet. Completion of this application does not guarantee adoption. Thank you! Name: ____________________________________________________________________________________________ Address: _________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Home phone: __________________ Cell phone: _______________________ Business phone: __________________________________________________ E-mail address: __________________________________________________ Name of the dog for which you are applying:_______________________ Ages of people in home:___________________________________________ __________________________________________________________________ Are any household members allergic to dogs? ______________________ Please list names, ages, and types of other pets in home: ________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Are your current pets spayed or neutered? ________________________ Are your pets up-to-date on their vaccinations? __________________ Please provide your veterinarian’s name and contact information: _________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Is this your first dog? __________________________________________ What percentage of the day will the dog live in the House ____________________________________________________ Yard _____________________________________________________ Do you have a fenced-in yard? ____________________________________ What height and type? _____________________________________ Does the fence have any holes? ____________________________ Do you have a doggy door into the home? __________________________ If you have had other pets, please tell us why you no longer have them: __________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Have you relinquished any pet to an animal shelter? ______________________________________________ If yes, please tell us the reason: _______________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Who will care for your pet while you go on vacation, have a medical emergency, or are away from home for an extended period? _____________________________________________________________________ __________________________________________________________________________________________________ Would you get the dog obedience trained if needed? ______________ Do you have a pool? ____________________ Is it fenced? __________ Is someone home during the day? _________________________________ How many hours will the dog be home alone daily? ________________ Do you own or rent your home? ___________________________________ If you rent, please provide your landlord’s name and phone number: _______________________________ __________________________________________________________________________________________________ If your dog is not house trained, how will you house train it? ___________________________________ __________________________________________________________________________________________________ Are you willing to have a H.A.L.T. representative do a home visit prior to adoption? _____________ If something happens to you, who will care for your dog? _________________________________________ __________________________________________________________________________________________________ Are you willing to pay veterinary expenses for regular care and for emergency care? ______________ Please list two personal references that we may contact: _________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Is there anything else you would like to tell us? ________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ By signing this contract you agree that all answers are true and correct. You agree that if you adopt, this application will become part of your contract and if any answers are found to be false or if you violate the contracts terms it becomes null and void and H.A.L.T. may take possession of the dog at any time without refund of any monies paid. Signature: ___________________________________________________ Date: ________________________________________________________