Description/Name of the dog you are interested in adopting:

Reasons for adopting this dog (check any that apply):
Family Pet	Child's Pet	Family Watchdog	Companion
Hunting Dog	Guard Dog for Business	Companion for other pet(s)	Gift
Other

Name:

Home Phone:

Cell Phone:

Address:

Time at this address:

City:

State:

Zip:

County:

Date of Birth:

(If you are over 60 years please ask about the Pets for People Program.)

Email Address:

Place of Employment:

Work Phone:

Occupation:

Time with current employer:

Have you applied to adopt or adopted from our shelter or other animal shelter before?

Yes No

If from another shelter, which one?

Previous Address (if less than five years at current address)

City:

State:

Zip:

County:

Name:

Home Phone:

Cell Phone:

Date of Birth:

(If you are over 60 years please ask about the Pets for People Program.)

Email Address:

Place of Employment:

Work Phone:

Occupation:

Time with current employer:

List names and ages of other members of your household:
Name:	Age:	Name:	Age:
Name:	Age:	Name:	Age:
Name:	Age:	Name:	Age:

Are the people in your home experienced with dogs?	Yes No
Is everyone in the household agreeable to getting a new dog?	Yes No

Does any member of your family have allergies to dogs? Yes No

If "yes", how severe is the allergy?

You live in a:

House

Apartment

Dorm

Mobile Home - Own land

Mobile Home Park

Do you:

Own

Rent

Live with your family

Do you have a fenced yard? Yes No

If "yes" please describe height and type:

If you rent or live with your family do you have your landlord/family's permission to have a pet?

Landlord/Park Manager/Home Owner's Name:

Phone:

What types of pets have you owned during the past 5 years? (Please list animals currently living with you also.)

Species	Name	Sex	Type/Breed	Kept Where	Age	Neutered/ Spayed?	Still Own?
		FemaleMale		IndoorsOutdoorsBoth		YesNo	YesNo
		FemaleMale		IndoorsOutdoorsBoth		YesNo	YesNo
		FemaleMale		IndoorsOutdoorsBoth		YesNo	YesNo
		FemaleMale		IndoorsOutdoorsBoth		YesNo	YesNo
		FemaleMale		IndoorsOutdoorsBoth		YesNo	YesNo

As an adult, have you ever had to give up a pet? Yes No

If "yes" what did you do with the pet?
Why did you have to give the pet up?

If you no longer have the pets listed above, please explain what happened to them:

Are your pets up-to-date on all vaccinations? Yes No I don't know I don’t have any pets

Which veterinarian do you use (or plan to use)?

Phone:

Whose name are the pets’ vet records listed under?

If you had to move in the future what would you do with your pet(s)?

Are you financially prepared to take on the added expense of a dog in your house (see cost of ownership) ?

Yes No

Do you plan to let your dog have puppies?	Yes No	If "yes", why?
Do you plan to spay/neuter your dog?	Yes No	If "no", why?

Approximately how many hours per day will your dog be alone (without human companionship)?

Please list the pet laws in the municipality where you live, that will apply to your dog:

If you need more information on pet laws in your area, please check here:

It may take your new dog two weeks or more to adjust to its new home.

Are you prepared to allow for this adjustment period? Yes No

Are you familiar with the needs of the breed you have chosen? Yes No

If you need more information on the breed you have chosen, please check here:

Who will be the primary caregiver?

Characteristics that best describe the primary care giver (check any that apply):
Retired	Stay-at-home parent	Employed part-time
Employed full-time	College student	Child/adolescent

How do you plan to prevent behavioral problems such as:

Housebreaking/Potty-training

Barking

Fence Jumping

Chewing

Digging

Inappropriate Jumping

Who will train your new dog? You Obedience class Other

Are you familiar with crate training? Yes No

Would you crate train this dog if it was necessary?

Where will your dog be kept:  During the day when you are home?

During the day when you are gone?

At Night?

How will you exercise your dog?

What type of ID will your dog wear?

Will you use a leash to walk your dog? Yes No

What brand of food do you plan to feed?

Dogs can live to be 15 years or older. Are you ready to take responsibility for the dog's entire life? Yes No

Any additional comments that you may have regarding this application:

The undersigned applicant hereby grants the Eau Claire County Humane Association permission to confirm any information provided in this application with any appropriate third party source, including landlords, veterinarians, etc. The information obtained will be held in confidence and used only by the Eau Claire County Humane Association for purposes of this adoption application. I certify that all the information on this application is true and complete. I understand that if any false information, omissions, or misrepresentation are discovered, my application may be rejected. I also understand that this adoption application is the sole property of the Eau Claire County Humane Association. It is specifically understood that the Eau Claire County Humane Association reserves the right to deny any adoption application at its own discretion.

Would you like more information on?
Becoming a member of ECCHA	Including ECCHA in your will	Volunteering

Electronic Signature:

Date:

Driver’s License Number: