Humane Society of Northwest Georgia

                                                                                    P.O. Box 3946

                                                                                                   Dalton, Georgia 30719

                                                                                                         706-226-5002

Please fill out the adoption questionnaire and submit same if you are interested in one or more of the animals. Pet ownership is a major responsibility with a life long  commitment to the adopted pet and should not be taken lightly. Please do not consider this questionnaire an invasion of privacy as this information is for humane society use only and is not disseminated to any other individuals, groups or agencies.

The Humane Society of Northwest Georgia reserves the right to deny an adoption for any reason.

Applicant:   Last Name:   First Name:   Age:   Occupation:

Street Address:     City:      State:     Zip Code:  

Home Phone:     Work Phone:    E-Mail:

Co-Applicant: Last Name:   First Name:   Age:    Occupation:

What is the name of the animal you are interested in ?:   Dog:   Cat:   Other:

May a representative of the HSNWGA visit your home for an inspection by appointment? (Yes or No):

Please check any of the following reasons for adopting this pet:  Family Pet:   Child's Pet:   Watchdog:   Barn Cat/Mouser:  

           Companion:   Hunting Dog:   Guard Dog for Business:   Gift:   Companion for other pet:  

           Other: (Explain)

Will this pet be a surprise for a family member? (Yes or No):     IF yes, who?   Their age:

Please indicate where you live: House:   Apartment:   Townhouse:   Mobile home in park:   Mobile home on property:

          Other:

Do you: (Own or Rent):    Do you have a fenced yard? (Yes or No):   How high and what type?

What is the Landlord's/Complex's phone number?   How much is the pet deposit?

How many times have you moved in past 7 years?  

Do you foresee any major changes in your life in the next 5 years, i.e.  Marriage:   Child Birth:   College:  

     Health problems due to age:     Other: (explain) 

Number of adults in household?    Do children live in the home? (Yes or No):  

What gender and age(s):

Does anyone in the household smoke? (Yes or  No?:   Do any family members have allergies?: (Yes or No):  

Explain allergies:

Number, type and age of pets currently in household:

Dogs =

Cats =

Do any of your current or did any of your past pets live primarily outdoors? (Yes or No):  

If yes, describe pet:

Were all previous pets Spayed or Neutered? (Yes or No):            Are all current pets Spayed or Neutered? (Yes or No):  

Do you know what Heartworm disease is and how to prevent it? (Yes or No):    

Do you use Heartworm prevention with current pets? (Yes or No): 

How often is it administered?       What brand do or did you use?

How do you plan on preventing Fleas and Ticks?

If adopting a dog, how will you handle destructive behavior? 

What procedures will you use for Housebreaking?  

If adopting a cat, how will you handle scratching/destructive behavior?

What is you veterinarian's name and phone number?

Please describe what happened to each of your past pets? (given away, put to sleep, died of old age, etc)

How many hours a day will the pet be left home alone?  

Where does you current pet(s) stay when home alone?

Where will your new pet stay when home alone during the day?   

Where do your current pets sleep at night?

Where will your new pet sleep at night?    What % of time will new pet spend indoors?

Do you have a pet door? (Yes or No):      Have you always kept an ID tag with your phone number on your pets? (Yes or No):

Under what circumstances do you think it's OK to leave a dog outside, alone and unsupervised in a fenced in area?

What circumstances, in your mind, justify giving up a pet?  Moving:     New baby:     Divorce:      Not getting along with other pets:  

          Getting out of fence:    Behavioral problems:    Children lost interest:    If it gets to big:   Becomes too time consuming:  

          Shedding:    Allergies:   Housebreaking problems:    Medical problems:    Aggressive behavior:

          Other: (explain)

Have you ever given up a pet or had a pet that didn't work out? (Yes or No):

If so, please explain the circumstances and what happened to the pet: 

Have you ever looked at or applied for a pet with another rescue group? (Yes or No):   If so, how long ago?

Did you adopt? (Yes or No):   Which shelter/rescue group?

If you date or marry someone who does not like or want your pets, what would you do?

What type of food will you feed your new pet? Dry:   Canned:    Brand name:

Has a dog, puppy, cat or kitten died on your premises in the last six months? (Yes or No):  

Explain circumstances:

Please list the names, address' & phone numbers of two references:

1. 

2. 

By submitting this application, I am attesting to the truthfulness of my answers. Falsification or omission of any of the above information will be

grounds for disallowing this adoption or possible removal of the pet from your home. Applicant must be 18 years of age or older.

Date of Application    Signature: _____________________________________________  Date: _______________

                                                                                      (Signature required upon adoption approval)