CANINE ADOPTION APPLICATION      (Rev 5/05)

                Name: _________________________________________________________________Date: _____________

            Address: ______________________________________________________________ Phone: _____________ 

            Email: __________________________________________________Driver’s Lic. #______________________

            I certify the following information is true and I understand that false information will nullify this adoption application.  I also authorize

my veterinarian to discuss with GHSI, any and all records pertaining

to my past and present pet(s).

            Veterinarian Name: ____________________________________________Phone:  _______________________

            Address:___________________________________________________________________________________         

            Do you live in a  ( ) House  ( ) Condo  ( ) Apartment  ( ) Mobile Home

            Do You  ( )Own  ( ) Rent      Landlord:______________________________  Phone:______________________

            How long have you lived at your current address:             _____________

            Have you applied to adopt a pet from us before:                ( )  Yes   ( )  No

            Have you ever brought an animal to a shelter:                    ( )  Yes   ( )  No

                        If so, circumstances:___________________________________________________________________

            If your pet gets lost what will you do to find him/her : ______________________________________________

            Will You neuter your pet:                                                           ( )  Yes   ( ) No

            Do all family members favor this pet:   ( ) Yes  ( ) No

            Who will be responsible for feeding and training this pet:_____________________________________

            Are any family members allergic to animals: ( )  Yes  ( ) No   Are there young children in the home: ( )  Yes ( ) No

            What other pets are currently in your home: _______________________________________________

            What pets have you had in the past & what happened to them: ________________________________

            How long will you allow your new pet to adapt to present pets and new surroundings? _____________

            How many hours a day will your pet be alone? _____________________________________________

            Do you plan to keep your pet       ( ) Indoors  ( ) Outdoors

                         If outdoors, how busy is your street with traffic:_________________________________________

                         If outdoors, what type of shelter will you provide: _______________________________________

            Do you intend to put identification on your pet:  ( ) Yes  ( ) No  What type:_______________________

            Dogs can live longer than 15 yrs, Are you ready to be responsible for its entire life:  ( ) Yes  ( ) No

            NY State law requires that pets have rabies vaccine; dogs require other inoculations as well, will you

                         make sure your dog gets these shots annually:                     ( ) Yes  ( ) No

            Why do you want to adopt a dog? : _______________________________________________________

            Describe the perfect dog for you: ________________________________________________________

            What type of behavior would you find difficult to deal with:___________________________________

            What would you do with your dog if it lost a limb, became blind, deaf or suffered some other physical disability:             __________________________________________________________________________

            What will you do with your dog when it becomes elderly:_____________________________________

            Are you ready to commit time and effort to the care, training and adjustment of this dog:  ( ) Yes  ( ) No                                 

            What would you do if your present pets did not get along with the new dog:______________________

            What would you do with your pets if you moved: ___________________________________________

            Do you object to a home visit or phone calls from a GHSI Representative? ________________________  

GOSHEN HUMANE SOCIETY, INC.  P O Box 37  Goshen NY 10924  (845) 294-3984