Dog Adoption Application Please enable JavaScript in your browser to complete this form.Home At Last Humane SocietyDog Adoption ApplicationApplicant must be at least 21 years of age to Adopt.Home At Last Humane Society reserves the right to refuse adoption to anyone who fails to comply with Home At Last Humane Society’s policies.I hereby give permission to Home At Last Humane Society to contact my veterinarian to obtain information about past and present pets. I also authorize Home At Last Humane Society to verify the below listed information.What Animal Are you interested in?Applicaion Date *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Applicant/Co-applicant ProfileYour Name *FirstLastCo-Applicant NameFirstLastDrivers license number & state *Phone *Alternate Phone Number (added to microchip)Email *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMailing Address (If Different)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHow long have you lived at this address? *Any plans to move in the near future? *YesNoDo you own of rent your home? *OwnRentIf you rent, do you have landlord permission to have an animal and have you paid all pet deposits? *YesNoIf you rent please supply Landlord Name, Address and Phone numberFamily/Household InformationHow many adults in the household? *Have all the adults in the household agreed to this adoption? *YesNoAre there children in household? (if none write none) *YesNoNoneAges of children in household (if none write none) *Any allergies to pets?YesNoif yes, explain. *Why would you like to adopt an animal from us? Check all that apply. *Companion for selfCompanion for childCompanion for another petCompanion for another household memberGuard/ProtectionIs this your first pet? *YesNoDo you currently have pets? *YesNoPlease list current pets. Name, Breed, age, gender, Spay/Neutered? *Have you ever given away or relinquished an animal? *YesNoIf yes please explain.Veterinarian InformationVeterinarian/Clinic Name (If None Write None)Veterinarian Phone *New Pet InformationIt takes time for animals to adjust to a new environment. Are you prepared to allow the time needed for your new pet to adjust to your home? *YesNoAre you committed to providing a responsible home for your pet’s entire life (10+ years)? *YesNoIf you have to move, what do you plan to do with your pet(s)?Who in the household will be the pets’ primary care giver?Where will the pet be kept during the day? *At night? *Please note that Home At Last does not adopt to outside only homes. Your new dog should be part of the family and therefore able to be inside the house.Do you have a fenced yard?YesNoIf no, how do you plan on containing your pet outside of your house? *How many hours per day will your pet be left alone? *What training techniques would you use if your pet: (Please be specific):Digging: *Barking: *Chewing: *Separation Anxiety: *Aggression: *How do you plan to house train your pet? *Failure to house train?: *Please Note Please understand that Home At Last Humane Society is not a veterinary clinic and that this animal may be harboring a medical condition which is not apparent during its stay at the shelter. Should such a condition become apparent after adoption, you assume full responsibility for any related veterinary care. We strongly recommend that you take advantage of the free office visit included in the adoption, within two (2) weeks of adoption. By clicking the submit button below, you have stated that all information on this application is true to the best of your knowledge. Home At Last Humane Society has the right to refuse an adoption if it is found that information stated on the application has been falsified. MessageSubmit