Pre-Adoption Application - Dog

Thank you for your interest in a TEARS rescue dog. Our goal with this questionnaire is to get the additional information needed to be sure there is compatibility between the animal & potential home. By answering these questions thoroughly & honestly we will be able to determine if the animal you are interested in would be a good fit for you & your lifestyle.
Please fill out this form in its entirety to be considered for a future adoption! Thanks!
Name of the dog Interested In:
Your Name:
Home Phone:
Work Phone:
Address:
(Including City, State, Zip)
Email Address:
Please check any of the following reasons you are considering adopting a dog:
Family Pet
Companion for Another Pet
Companion for Self
Child's Pet
Breeding 		Protector for Self/Family
Watchdog/Business
Gift
Other
Is everyone aware of and in agreement regarding the potential adoption of a dog? Yes No
Please check any of the following that match what you are looking for in a new dog:
Adult weight 50+ lbs
Adult weight 25 -50 lbs
Adult weight less than 25 lbs
Active, energetic
Calm, easy going 		Likes to run, hike, swim, etc.
Easily trained
Independent
Protective
Are there children in the household? Yes No
If so, what are their ages?
I live in a:
House Apartment Condo Town Home Mobile Home
Do you rent or own? Rent    Own
If you rent:
  • What is the name of your apartment or landlord and their phone number?
    		•
  • Does your lease allow pets?
    		•  Yes    No    N/A
  • What is the weight limit?
    		•
    How long will the dog be home alone on the average day?
    Where will this dog be allowed? Please check all that apply
    During the day -
    Inside house w/limited access Inside house w/free roam Outside
    At night -
    Inside house w/limited access Inside house w/free roam Outside
    When home alone -
    Inside house w/limited access Inside house w/free roam Outside
    When visitors come -
    Inside house w/limited access Inside house w/free roam Outside
    Do you have a fully fenced yard? Yes No
  • Is the fence attached to the house?
    		•  Yes No
  • What is the height of the fence?
  • What is the fence made out of?
  • What is the size of the yard?
  • Have you ever found it necessary to chain or tie out your dog?
    		•  Yes No
  • If yes, please explain why:
  • Have you ever had a hard time keeping a dog in your fence?
  • If yes, please explain why:
    		•
    Do you own any other pets? Yes    No Types
    Are you willing to provide any training or reinforce prior training if necessary? Yes    No
    Which of the following ways would you be willing to do:
    Group classes
    One-on-One Training
    Self by book/DVD/Internet     		Positive reinforcement
    Punishment
    Other
    Does anyone in your family suffer from or been diagnosed with allergies and/or asthma? Yes    No
    If yes, what precautions are you planning to take:
    Have you or anyone in the household ever been given a citation or convicted of violating any Federal, State, County, City or Municipal animal codes/laws? Yes    No
    If yes, please describe:
    For which of the following reasons would you give up or return this dog?
    Please check all that apply:
    Moving
    New Baby
    Behavior problems
    Not getting along with other pets
    Allergies
    Divorce
    Financial     		Destructive
    Medical problems with pet
    Aggressive Shedding
    Digging
    None
    Other:
    Have you ever surrendered an animal to an animal shelter/pound/humane society? Yes No
  • If so, explain:
    		•
    Has a pet died while living in your care? Yes No
  • If so, explain:
    		•
    Please answer the following questions honestly:
  • Have you ever had a pet stolen?
    		•  No Yes (please explain):
  • Have you ever had a pet poisoned?
    		•  No Yes (please explain):
  • Have you ever had a pet killed by a vehicle?
    		•  No Yes (please explain):
  • Has a pet of yours ever died form a disease?
    		•  No Yes (please explain):
  • Has a pet of yours ever been killed by another animal?
    		•  No Yes (please explain):
  • Would you allow a dog to ride in the back of a truck?
    		•  No Yes (please explain):
    Do you currently own a dog/dogs? Yes No
    In the last 5 years? Yes No
    If so, how many and what kind?
    Current pet(s) names:
    Are your pets spayed or neutered? Yes No
  • If they are not, what is the reason?
    		•
    Do your pets live:
    Indoors Outdoors Both Other:
    Are your pets current on all shots? Yes No
    Are your pets on heartworm preventative? Yes No
  • If yes, brand name of Heartworm Preventative:
    		•
  • If not, what is the reason?
    		•
    Will you be taking your new pet to the vet for full prevention and medical care once a year? Yes No
    Please provide your Vet Clinic that you take your current pets and would take your new pet.
    Phone number of above Vet Clinic:
    Do you mind if we call your vet for a reference? Yes No
  • Account Name at Vet Clinic:
    		•
    Would you object to an authorized TEARS representative inspecting the animal you are considering adopting in addition to the premises where the pet would be living? Yes No
    I attest that the information I have provided here is true and accurate. I understand that if any portion is erroneous or misleading it may cause or lead to the confiscation of the animal.

    TEARS · 226 Glasgow Road · Birmingham, AL 35224
    Phone: (205) 744-3373 · Emergency Pager: (205) 619-1020