DOG Adoption Application If you are interested in applying to adopt a DOG, please fill out the form below. Adoption Application: DOG Step 1 of 4 25% Which animal(s) are you interested in adopting?* PERSONAL INFORMATIONName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Cell NumberWork NumberEmail* Date of Birth* MM slash DD slash YYYY Occupation* HOUSEHOLD INFORMATIONPlease list the members of your household (names and ages)*Who will be primarily responsible for the care of this animal?* Have you ever been charged with an animal related crime?* Yes No Do you live in a:* Single Family Home Apartment or Condo Mobile Home Townhouse Dormatory Farm Do you:* Own Rent Live with parents Do you have a fenced-in yard?* Yes No Where will the animal stay during the day?* Where will the animal stay at night?* Where will the animal stay when no one is at home?* How long will the animal be alone during the day on average?* LIFESTYLEDo you plan on breeding this animal?* Yes No Are you willing to work through any behavioral problems with your adopted animal?* Yes No What behaviors are you not willing to tolerate? (hold down the Ctrl key to select more than one))*MouthingNippingJumpingBarkingHousetraining issuesDestructive chewingNoneAre you willing to give the animal at least 6 weeks to adjust to its new environment?* Yes No Are you willing to enroll in a training class with your new dog?* Yes No Do you agree to take your adopted animal to a vet within 7 days of adoption?* Yes No Would you be willing to make a donation to help the other homeless animals of HSHC?* Yes No Please list all your current pets and all the pets you have had in the past 5 years: (use the (+) to add additional pets)*Pet’s NameSpeciesBreedAgeSexSpayed or Neutered? (Yes or No)If you no longer have this pet, where are they now? If your current pets are not up to date on vaccinations or spayed/neutered, please explain why:Have you ever had to give an animal away?* Yes No If yes, what were the circumstances? Who is your veterinarian?* Veterinarian's PhoneDo you understand that your adopted animal may require additional veterinary care as a result of being exposed to shelter related illnesses (i.e. kennel cough)?* Yes No I understand that the falsification or omission of any of the above information will result in automatic refusal of adoption or confiscation of the adopted animal. I authorize HSHC to verify the validity of any information contained in this application. I hereby agree to release, discharge, indemnify and hold harmless the Humane Society of Harford County and any of its agents from any and all liabilities that may arise out of the handling by me and/or my party.Consent* I agree to the application policySignature* Date* MM slash DD slash YYYY CAPTCHA