This is for pet dog adoptions only. This is not for prospective clients interested in guide dog partnerships or prospective volunteer puppy raisers. Thank you.Today's Date MM slash DD slash YYYY Applicant's Name* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email Address* Phone (Day)*Phone (Evening)*Household/Pet ExperienceHave you owned a dog before?* Yes No If "YES", list Breed(s)*Have you had a Fidelco Shepherd before?* Yes No If you have ever obedience-trained dogs, please describeWhat became of your most recent dog(s)?*Are there any of the following in the home? (check all that apply)* Children (family members) Children (frequent visitors) Individuals with dog allergies Senior Citizens (family members) Senior Citizens (frequent visitors) Persons with special needs None of the above Your Age* 20-45 46-55 56-65 66-75 76+ Please list all other people residing in your home with ages*What sort of exercise can you provide for the dog? (check all that apply)* Fenced yard Jogging Leash walking Other Other*For how long each day will the dog be alone?*Dog will live primarily* indoors as a house pet outdoors in a doghouse Describe age, sex, spayed/neutered, and breed(s) of other dog(s) in the home, if any*Do you have pets other than dogs in the home?* Yes No If "YES", please describe*Pet RequestDo you want a Fidelco dog primarily for (check all that apply)* Family pet Companionship Watchdog Obedience Competitions Other Do you prefer a (check all that apply)* Puppy (under 2 years of age) Mature dog (over 2 years of age) Retired dog Do you prefer a* Male Female Either male or female Would you consider adopting a dog, at no charge, with a medical problem that may require medication, exercise restrictions, or other special needs?* Yes No Financial StabilityAre you employed?* Yes No Employer*Address*Job Title*Do you have the ability to financially support a pet (approx $140 per month)?* Yes No Monthly household income*Criminal RecordHave you ever been arrested or convicted of a crime?* Yes No If "YES", please include dates and details*Personal ReferencesPersonal Reference #1* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Email* Relationship*Years*Personal Reference #2* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Email* Relationship*Years*Your VeterinarianName* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Additional Comments or InformationIs there anything else you would like us to know?EmailThis field is for validation purposes and should be left unchanged.
