Adoption - Canine Please list the Name of the animal you are interested in adopting.*Your Name* First Last Driver's License / ID#*Date of Birth* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home Phone*Work PhoneCell PhoneEmail* Emergency Contact (Full Name) First Last Emergency Contact PhoneHouseholdWhat type of housing do you live in?*HouseCondoMobile HomeParent's HomeApartmentDo you rent or own your home?*Select oneRentOwnIf renting, do you have your landlord's permission to adopt a pet?*YesNoPlease list the names of all your household members. Include ages for those under 18 years.*Who are you adopting this pet for?*SelfChildrenFamilyGiftOther PetWho will be primarily responsible for the care and supervision of the animal?*Will this dog be in the presence of children frequently?*YesNoIf yes, what ages are the children?My adopted dog will primarily be an...*Indoor CatIndoor / Outdoor CatOutdoor CatHow will you confine your adopted dog to your property when outdoors?*When I'm not at home, my dog will spend his / her time...*In the garageIn crateLoose in houseLoose in yardLong Term CareWhat will happen to this dog if you move?*Do you have a Veterinarian for your pet(s)?*YesNoN/AIf yes, please list the name of the clinicApproximate date of last vaccinations for your current pet(s)How many pets are in your home?Are all your pets spayed or neutered?Please list the pets that you have had in the past five years (both current and those you no longer own)Breed / Age / Gender / Spayed or Neutered / How long owned? / What happened to him or her?By submitting this form, you certify that this information is true and understand that false information may result in nullifying this adoption. This questionnaire remains the property of the Pet OverPopulation Prevention.