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HELP the Dogs
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HAPPY Tails
Friends of MomsVA
HOME
Find a BEST FRIEND
HELP the Dogs
JOIN the TEAM
HAPPY Tails
Friends of MomsVA
MomsVA Animal Adoption Application
Thank You for your interest in adopting a rescued canine orphan.
Please give yourself ample time to complete this application. Our goal is to make lifelong matches for dogs and people.
Because
MomsVA is run solely by volunteers, p
lease allow us time to review your completed application. We will contact you as soon as we can.
This form is confidential
:
This form is designed to help you find the dog or puppy most compatible with your lifestyle. MomsVA will maintain the information provided below as confidential and will not share your information with any outside individuals or organizations without your express consent. Completion of this application does not obligate you in any way or guarantee the adoption of a MOMS dog or puppy. MOMS reserves the right to approve or deny any application for any reason and the right not to disclose the reason.
All dogs are spayed/neutered prior to adoption:
All MomsVA adult dogs and puppies are spay/neutered prior to adoption.It is possible that an approved adopter may experience a short waiting period (for spay/neuter to occur) between being approved and being able to take the dog or puppy home. In the event this occurs, we thank you for your patience.
Please complete all the following questions completely to the best of your knowledge.
Be sure to complete questions with a red *
. These items are required and your information will not forwarded to us if any of them are left blank.
Applicant information
*
Indicates required field
If applicable, name(s) of the dog(s) on our website that interest you:
*
Your Name
*
Breed(s) of dogs that interest you
*
WORK Phone Number
*
HOME Phone Number
*
CELL Phone Number
*
Are you over 18 years of age?
*
Yes
No
BEST contact number
*
WORK Phone
HOME Phone
CELL Phone
Email Address
*
Your Complete Address (ex: 123 Main Street, Puppytown, VA, 45678)
*
Are you over 70 years of age?
*
Yes
No
Your Occupation
*
Your Employer's Name
*
Employer's Address (city, state, and zipcode)
*
Household Information
Names of other adults in your household
*
Names & Ages of children in the household
*
Other Adult's Occupations (include employer name(s) and addresses)
*
Are you aware of your county's or city's number of allowed pets?
*
Yes
No
Who will be the primary caregiver for your new dog/puppy?
*
Is this the first dog for you and your family?
*
Yes
No
Are all the adults in your household aware that you are adopting a dog or puppy?
*
Yes
No
Planning as a surprise/Gift
Does any member of your household have pet allergies?
*
Yes
No
Not Sure
Who is financially responsible for your current pets?
*
Current pets?
1) Other pet in the House (Name, Breed, Age)
*
Gender
*
Male
Female
Spayed/Neutered
*
Yes
No
Current on Vaccinations?
*
Yes
No
Unsure
Name of current veterinarian
*
Veterinarian address (street, city, state)
*
Veterinarian Phone Number (w/area code)
*
Names of pets with records at this vet
*
Owner name on the records at this vet
*
If your current vet has seen your pet for less than 1 year, please provide the name & number of your previous vet below.
*
2) Other pet in the House (Name, Breed, Age)
*
Gender
*
Male
Female
Spayed/Neutered?
*
Yes
No
Current on vaccinations?
*
Yes
No
Unsure
Name of current veterinarian
*
Veterinarian address (street, city, state)
*
Veterinarian Phone Number (w/area code)
*
Names of pets with records at this vet
*
Owner name of the records at this vet
*
If your current vet has seen your pet for less than 1 year, please provide the name & number of your previous vet below.
*
3) If there are other pets in the household, please use the space below to provide the same information for those pets.
*
Is there any additional information about your current pets that you would like us to know?
*
Other previous pets?
If you previously have had other animals/pets, please complete the following:
1) Pet Name
*
Breed
*
Spayed/Neutered
*
Yes
No
Years owned
*
Where is this pet now?
*
Name of veterinarian for this pet
*
Location of this vet (city, state)
*
Veterinarian Phone Number
*
Owner name for the records at this vet
*
2) Pet Name
*
Breed
*
Spayed/Neutered
*
Yes
No
Years Owned
*
Where is this pet now?
*
Name of veterinarian for this pet
*
Location of this vet (city, state)
*
Veterinarian Phone Number
*
Owner name for the records at this vet
*
Is there any additional information about your prior pets that you would like us to know?
*
Has anyone in your household EVER given a pet away?
*
Yes
No
Has anyone in your household EVER released a pet to an animal shelter or rescue?
*
Yes
No
Has anyone in your household EVER sold a pet?
*
Yes
No
If YES to any of the last 3 questions, what were the circumstances?
*
Lifestyle Information
What temperament and activity level are you seeking in a dog?
*
Athletic/High Energy
Affectionate
Mellow
Quiet
Lap Dog
Are you adopting a dog for any of the following reasons?
*
Hunting dog
Guard Dog/Protect Property
What do you hope a new dog/puppy will add to your life?
*
Do you own or rent?
*
Rent
Own
If renting, please provide your LANDLORD'S NAME and contact phone number:
*
How many hours each day will the dog or puppy be left alone?
*
Where will the puppy/dog be kept when alone? (select all that apply)
*
Indoors
Outdoors
In a dog crate
If indoors and not crated, in what room will the dog/puppy be kept?
*
What type of housing do you live in (single family house, apartment, townhouse, etc.)
*
Do you have a completely fenced yard?
*
Yes - electric fence
Yes- material fence
No
If FENCED, what is its height? (3 ft, 4 ft, 6 ft, etc.)
*
If FENCED, what type? (picket, privacy, split rail, post-and-rail, chain link,etc.)
*
Is there a gate?
*
Yes
No
Do you have a pool?
*
Yes
No
Is there a fence around the pool?
*
Yes
No
Where will the dog/puppy be kept during the day when you are home?
*
What type of exercise will you give the dog/puppy?
*
Realistically, how many hours per day do you have to exercise with and/orplay with your dog?
*
Less than 1 hour
1-2 hours
2-3 hours
More than 3 hours a day
Where will the dog/puppy sleep at night?
*
How often will the dog/puppy get exercise?
*
Are there times when the dog will be tied outside?
*
Yes
No
If YES, when and for how long on average?
*
Training and development
Do you plan on attending obedience classes with your new dog/puupy?
*
Yes
No
Unsure
What methods will you use to train your new dog/puppy?
*
Do you know what causes heartworms?
*
Yes
No
Unsure
Do you agree to keep your dog/puppy on heartworm preventative all year round?
*
Yes
No
How much are you willing to spend annually on medical bills for the dog/puppy?
*
What would you do if the vet bills go over this amount?
*
If your new dog/puppy has an accident in the house, how will you correct him/her?
*
How long do you think housebreaking will take?
*
When you go on vacation, who will care for your dog/puppy?
*
If you move, what will you do with your dog/puppy?
*
Have you ever incurred extraodinary or unexpected vet expenses?
*
Yes
No
If yes, please explain
*
Are you ready to take responsibility for this dog/puppy for the next 10-15 years?
*
Yes
No
What provisions will you make for the dog/puppy should you become unable to care for it?
*
Have you previously applied to adopt a dog, puppy, cat or kitten from a rescue group or shelter?
*
Yes
No
If yes, when and what rescue group or shelter?
*
What was the result of the application?
*
Are you willing to have a MomsVA representative visit where the dog/puppy will be living?
*
Yes
No
Unsure
References
Please provide TWO personal references of someone not living in your home.
1) REFERENCE Name
*
1) Reference Phone Number
*
1) Relationship to you
*
2) REFERENCE Name
*
2) Reference Phone Number
*
2) Relationship to you
*
Is there anything else that you feel we should know?
*
AUTHORIZATION/RELEASE
By signing (spelling out your full name on this form) below and submitting this form, I certify that all information given in this application is true and correct, to the best of my/our knowledge. By submitting this form, I hereby further grant consent to MOMS and its agents to seek information about me from all named and unnamed sources within this application, including but not limited to veterinarians, rental agents, and personal references, regarding this application. Providing false information or refusing to sign below will result in the rejection of the application or the nullification of the adoption agreement.
Printing your name represents your official signature in the space(s) below.
Signature/Name of Applicant
*
Signature/Name of second applicant if applicable
*
MomsVA reserves the right to approve or deny any application for any reason and the right not to disclose that reason.
BEFORE you click SUBMIT, please note:
Please check that you have completed all questions where there is a red
*
(these are required).
Once you have filled in all the
*
fields and hit SUBMIT, wait until this page refreshes and you see a confirmation message that says your information has been sent to
[email protected]
for review.
We are not able to send confirmation emails at this time. As long as you see the confirmation page, your information has been sent to us.
If the page
does not refresh
, look for a message
under the SUBMIT button
that says
"Please correct the highlighted fields."
Then
go back through the application and fill in any i
tem on the form where there is a red
*
and hit SUBMIT.
We look forward to receiving your completed form!
Submit
