Adoption - Canine Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please list the name of the dog you are interested in adopting.*Your Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How long have you been at this address?Daytime Phone*Evening PhoneWhat is the best time to call?Email* Emergency Contact (Full Name) First Last OccupationFamily & HousingHow many adults are in your household (and their relationship to you)?How many children are in the household (ages)?*What type of home do you live in?*HouseCondoRVParent's HomeApartmentFarmDuplexWhat type of fencing do you have (and how tall)?Please describe your householdActiveNoisyQuietAverageDo you rent your home?YesNoIf you rent your home, please give the rules governing pets as well as provide your landlord's name and numberBy providing this information, you are allowing POPP to contact your landlord. Please inform them of this so they will speak to us when we call.Does anyone in the family have an allergy to dogs?*YesNoI don't knowIs everyone in agreement with the decision to adopt a dog?YesNoOther PetsWhat other pets do you have (specify type and number)?Are these pets up to date on vaccines? If not, why?YesNoNot applicable to the speciesAre these pets spayed/neutered? If not, why?YesNo. Too youngNo. Health conditionNo. BreedingNo. ShowingNot applicable to the speciesHave you ever rehomed a pet? If yes, why?Have you ever euthanized a pet? If yes, why?NoHealth conditionBehavior problemsCould not find it a new homeOtherHave you ever lost a pet due to an accident? If yes, please explain.How do you discipline your pets? What behaviors do you believe require discipline?VeterinarianDo you have a family veterinarian?YesNoWhat is the veterinarian's name, clinic name, address and phone number?By providing this information, you are allowing POPP to call your veterinarian. Please call your vet and authorize them to release the information to POPP.The Dog You Wish to AdoptWhere will the dog spend the day?*Where will the dog spend the night?Number of hours (average) the dog will spend alone?When I'm not at home, my dog will spend his / her time...*In the garageIn a crateLoose in houseLoose in yardWho will have primary responsibility for this dog's daily care?Who will have financial responsibility for this dog?What will happen to this dog if you move?*Do you agree to provide regular health care by a licensed veterinarian?YesNoDo you agree to keep this dog as a indoor companion?YesNoIf you are no longer able to keep this dog, do you agree to contact POPP?YesNoA home check is required to ensure the safety and well-being of POPP's dogs prior to approval of adoption. Are you willing to allow a representative of POPP to visit your home by appointment?YesNoHow did you hear about POPP?PetSmartPet of the Week media spotAdopted previouslyFriendSocial MediaPet FinderOtherBy submitting this form, I certify that this information is true and complete. This dog will reside in my home as a pet. I will provide it with quality dog food, plenty of fresh water, indoor shelter, affection, annual physical examination and vaccinations under the supervision of a licensed veterinarian. I understand that false information may result in nullifying this adoption. This questionnaire remains the property of the Pet OverPopulation Prevention.