Dog Adoption Survey

Name of Dog You Would Like to Adopt

PRIMARY ADOPTER INFORMATION

Name (First & Last) (required)

Driver's License Number & State (required)

Please leave this field empty.

Address (required)

City (required)

State (required)

Zip (required)

Home Phone (required)

Cell Phone (required)

Work Phone

Email (required)

Your Age (choose one) (required)
18 or Under19-2021-5455+

Your Employment Status (required)
EmployedUnemployedRetiredStudentOn Disability

Your Occupation

Name of Employer

Employer Phone Number

Are you allergic to pets? Please describe your allergies below (if applicable) (required)
YesNo

Personal Reference #1 (Include Full Name and Phone Number) (required)

Personal Reference #2 (Include Full Name and Phone Number) (required)

CO-ADOPTER INFORMATION

Name (First & Last) (required)

Driver's License Number & State (required)

Address (required)

City (required)

State (required)

Zip (required)

Home Phone (required)

Cell Phone (required)

Work Phone

Email (required)

Your Age (choose one) (required)
18 or Under19-2021-5455+

Your Employment Status (required)
EmployedUnemployedRetiredStudentOn Disability

Your Occupation

Name of Employer

Employer Phone Number

Are you allergic to pets? Please describe your allergies below (if applicable) (required)
YesNo

Personal Reference #1 (Include Full Name and Phone Number) (required)

Personal Reference #2 (Include Full Name and Phone Number) (required)

HOUSEHOLD INFORMATION

Number of adults (18+ yrs) in household. List full names of all adults in household below. (required)

Number of children (under 18 yrs) in household. List ages of all children in household below. (required)

List all current companion animals (including farm & caged animals) and any other animals your new dog would be sharing the house with (regular visitors to your home). Use "N/A" in all fields if you have no other companion animals. (required)
Companion Animal 1

Companion Animal 2

Companion Animal 3

If you run out of space, list additional companions below. Include all of the same information as the 3 listed above.

If you have other companion animals, how do you think they will adjust to a new animal?

How much time will you give your new companion to adjust to their new surroundings? (required)

Excluding current companions listed above, please describe all pets you have had in the last 5 years. (required)

What is your home like? (choose one that best fits) (required)
Quiet & Low KeyModerate Noise Level & VisitorsBusy! Lots of Visitors Coming/Going - Noise

Are you willing to have an A.S.K. representative come to your home to see where this companion will be living? (required)
YesNo

RESIDENCE INFORMATION

Housing Type (required)
House (Own)House (Rent)ApartmentCondoMobile HomeOther

How long have you been at your current address? (Years/Months) (required)

If you do not own, provide landlord's full name and phone number.

Yard Type (check all that apply) (required)
Open YardFenced-In YardDog KennelTie Out or ChainInvisible FenceOther

If you have a fenced-in yard with a gate, what is used to secure the gate?
LatchLockDeadboltPadlock

Are you planning on moving in the next 12 months? (required)
YesNo

What will you do with the dog if/when you move?

COMPANION CARE

Are your companion animals up-to-date on vaccinations? (required)
YesNoNot Applicable

Your current or former veterinarian's information. (required)

Where will your dog primarily live? (required)
OutsideInside

Who will be responsible for feeding/watering your dog? (required)

Approximately how many hours will your dog spend outside per day? (required)

How will you exercise your dog? (required)

Approximately how many hours will your dog be alone per day? (required)

What is your daily schedule? (choose all that apply) (required)
Home All DayHome 1/2 DayAway 7-10 HoursAway 10+ HoursAllowed to Bring Dog to Work

When you are not home, where will the dog be? (choose one) (required)
CrateOutsideGarageBasementConfined to One RoomLoose in HouseOther

Where will your dog go while you are on vacation? (required)

If you become ill or die, do you have plans for your animal's care? (required)
YesNo

Can you afford for your dog to be on heartworm preventative treatment? If you don't know what this is, please ask us. (required)
YesNo

Bad habits you will not tolerate from your dog: (required)

How will you handle destructive behavior? (required)

What methods will you use to discipline your dog? (required)

MISCELLANEOUS

Are you currently a dog parent? (required)
YesNo

Have you previously been a dog parent? (required)
YesNo

Where did you obtain your dog(s) from? (choose all that apply) Please include name of shelter/rescue, breeder, explanation of "other" below. (required)
FriendFamily LitterBreederRescue/ShelterOther

Have you ever adopted an animal from a shelter or rescue? (required)
YesNo

Have you ever given an animal to a shelter or rescue? (required)
YesNo

Have you ever had to find a different home for a former companion animal? Share what led you to this decision and where the animal went. (required)
YesNo

Check all that apply for this dog adoption: (required)
I want a guard dog.I want dog to herd/hunt for me.I want dog to be playful with me.I want dog to be laid back.I would like dog to be in a training class to address leash manners, jumping, etc.I want dog to be in competitions.I want a dog with special needs (include behavioral issues, senior age, health issues).

Under what circumstances would you return this animal to A.S.K.? (Check all that apply) For "other" choice, please explain below. (required)
Neighborhood complaintsBreed stereotypesDog doesn't get along with other companion animalsDog is un-trainablePlanning on having a childBig vet billsDog develops chronic illnessI develop a chronic illnessMarry someone with allergiesDog bites childrenDog nips at strangersDog barks a lotMove where dogs aren't allowedMove out of stateDivorce/separationDoes not applyOther

Final comments you would like A.S.K. to know:

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