First Name * Last Name *
State * Zip *
Email Verify (Please type again) *
Home Phone * ( ) -
Cell Phone ( ) -
Work Phone ( ) -
Drivers License #
How Many Yes
Ages of Children Yes
Interested in: Kelly
Own Mobile Home
Rent Mobile Home
Have screens on windows?
Have secured fencing in yard?
'Kelly' will be kept
Location inside, either during the day or night
All rooms in the house
The living room
Location outside, either during the day or night,
Protected from the elements ( rain / sun etc )
Unprotected - Open to the elements, with no shelter
Length of time at current address
Landlord Name *
Landlord Phone *
Current Pets: * Please include all pets, including small caged and barnyard animals
and list the following for each pet: Type of Pet, Age, Sex, Spayed/Neutered, Kept In/Out, How long owned
Pet History: * Please list pets owned in the past 5 years (other than those above)
and list the following for each pet: Type of Pet, Spay/Neutered, Kept In/Out, How long owned, What happened to pet
Veterinarian: * Please enter the following if you currently own animals or if you have owned
animals in the past: Veterinarian Name, Address, Phone
Responsibility: * Who will be responsible for the pet’s care?
Experience Level Please describe your experience with owning a dog:
( 1=No experience to 5=Lots of experience ) 1
Experience: Please explain in detail your experience in owning a dog from the rating above:
Temperament: What type of temperament are you looking for in a dog and why?
Exercise: How often will you exercise your dog and how much exercise do you think a dog needs weekly?
Training: Have you ever attended any dog training classes ( if so when/what type)? If needed would you be willing to attend training with 'Kelly'?
About: * Why are looking to adopt a dog or specifically 'Kelly'?
Length of time during the day 'Kelly' will be left alone? *
If extended trip,'Kelly' will be taken care by?
* What do you consider an acceptable reason for giving up an animal?
Comments or Questions:
Where did you hear about AHAN?
Other Search Engine
Word of Mouth - friend, family
Bay Area resource - flyer, poster, protest
Have you ever adopted an animal from a shelter, rescuer group or organization before?
If yes, what was the name and city
of the shelter, rescuer group or organization:
Were you satisfied with your experience with them?
If not satisified, what was
I hereby authorize to release AHAN all veterinary records on any and all animals I own or have owned: Yes No
I have downloaded and read the following , am willing to abide by it and will sign it if I am selected to adopt the animal as well as I am willing to pay an adoption fee which covers the animal rescue, adoption and medical expenses. adoption agreement *** Important Application Printing Instructions *** Yes No
I certify that all the information in the application is true and I understand that false information may void the application and I understand that submitting of this application is no guarantee that I will be able to adopt the animal that I have selected to adopt. Yes No
Choose a second choice if 'Kelly' is unavailable?
Currently: None Chosen
Security Field to Prevent Automatic Form Submission: Please select a color from the following pulldown: *