Newnan-Coweta Humane Society and Shelter Rescue

Contact information: Applicant
First Name
Middle Initial
Last Name
Age
Occupation
Contact information: Co-applicant (Spouse orSignificant Other)
First Name
Middle Initial
Last Name
Age
Occupation
Street Address
City
County
State
ZIP
Home Phone
Work Phone
Email Address
Name of dog/puppy you are interested in adopting
List any general questions you would like to ask about this particular pet
Are you willing to allow a representative from NCHS to visit your home by appointment?	- Select from the following - Yes No
Please check any of the following reason(s) for adopting this dog/puppy - you can select more than one.	- choose one or more - watchdog companion hunting dog guard dog for business companion for other pet gift other - please specify
Please indicate where you live	- Select from the following - apartment house condo/townhouse trailer/mobile home
Do you......	- Select from the following - rent own
If you rent, do you have the landlord's permission to own a dog/puppy?	-Select from the following - Yes No
What is the apartment complex name?
What is the landlord's phone number?
How much is the pet deposit?
How many times have you moved in the past 5 years?
If you move, will your pet go with you?	- Select from the following - Yes No
Would you ever consider moving somewhere that doesn't allow your pet(s)?	- Select from the following - Yes No
Do you foresee any major changes in your life in the next 15 years (average lifespan of a dog) such as marriage, childbirth, health problems due to age, going away to college?	- Select from the following - Yes No
If yes, please explain
Do you or anyone in your household currently have any serious health problems?	- Select from the following - Yes No
If yes, please describe
Can you provide a permanent home for this dog/puppy for10-15 years?	- Select from the following - Yes No
What procedures will you use for housebreaking?	- Select from the following - Crate Training Newspaper Rubbing Nose Swatting With Newspaper Ouside Only Other
If you selected "other", please describe
Do you have a fully fenced yard with no fence gaps?	- Select from the following - Yes No
If yes, how high and what kind?
If no, would you consider fencing all or part of it as a condition of adopting a dog?	- Select from the following - Yes No
If no fence, how do you plan to keep the pet on your property?	- Select from the following - Chain Runner Tie-Out Leash Walk Pen/Kennel Run Free Other
If you selected "other", please specify
Number of adults in household
Relationship:	- Select from the following - Spouse Roommate(s) Life Partner Other
If you selected "other", please specify
Will this dog/puppy be a surprise for any family member?	- Select from the following - Yes No
If yes, who?
Do any family members have allergies?	- Select from the following - Yes No
Do any children live in the house?	- Select from the following - Yes No
If so, what are their ages?
Number, type and age of pets currently in household
Do any of your current or did any of your past pets live primarily outdoors?	- Select from the following - Yes No
If yes, please describe pet
Were all previous pets spayed/neutered?	- Select from the following - Yes No
Are all current pets spayed/neutered?	- Select from the following - Yes No
Do you know what heartworm disease is and how to prevent it?	- Select from the following - Yes No
Is your current dog or was your previous dog on heartworm prevention medication?	- Select from the following - Yes No
If yes, how often did you give the heartworm medication?
What brand did you use?
What is your veterinarian's name and phone number?
What do you expect annual pet care (vet care, medication, heartworm preventative, etc.) to cost yearly?
How many dogs have you owned in the past?
If any, please describe what happened to each of them (put to sleep, run over, died of old age, sold, given away, ran away, etc.)
Who will be responsible for the daily care and training of your new dog/puppy?
How do you plan to prevent fleas and ticks?
Are you aware of Frontline or Advantage?	- Select from the following - Yes No
How many hours will the dog/puppy be home alone on a typical day?
Where does your current dog stay when home alone during the day?	- Select from the following - Outside in fenced area Outside in dog pen Outside on chain or tie-out Inside in basement In the garage inside free run of the house inside in one room of the house inside in a crate Other
If you selected "other", please describe
Where will your new dog/puppy stay when home alone during the day?	- Select from the following - Outside in fenced area Outside in dog pen Outside on chain or tie-out Inside in basement In the garage inside free run of the house inside in one room of the house inside in a crate Other
If you selected "other", please describe
Where do current pets sleep at night?	- Select from the following - Doghouse in fenced area Doghouse in dog pen Doghouse near chain or tie-out Inside in basement In the garage inside free run of the house inside in one room of the house inside in a crate In my bed Other
If you selected "other", please describe
Where will your new dog/puppy sleep at night?	- Select from the following - Doghouse in fenced area Doghouse in dog pen Doghouse near chain or tie-out Inside in basement In the garage inside free run of the house inside in one room of the house inside in a crate In my bed Other
If you selected "other", please describe
What percentage of time will the dog/puppy spend inside the house?
Have you ever had a serious behavior problem with a previous dog?	- Select from the following - Yes No
If so, please describe
Do you have a doggie door?	- Select from the following - Yes No
Would you consider installing a doggie door?	- Select from the following - Yes No
Have you always kept an ID tag (other than a rabies tag) bearing your phone number on your pets?	- Select from the following - Yes No
Are you willing to keep a collar and ID tag on all your pets including a new dog at all times?	- Select from the following - Yes No