Name (first, middle initial, last):
Address (city, state, and zip code):
Home phone number:
1. YOUR FAMILY AND NEIGHBORS:
Are there other adults in your household? YES NO
(Please circle answer)
Do they agree with your decision to get a dog?
If not, what reason do they have for not wanting a dog now?
Are there children in your household?
If so, how many and what ages are they?
Are you frequently visited by children? YES NO
If yes, do any of them have access to your yard/kennel/house
when you are not at home? YES NO
If yes, explain, please indicate how you intend to prevent them
from teasing a dog, letting a dog out either intentionally, or by
accident, or doing any other thing that might be detrimental to the
welfare of a dog in your care.
Is anyone in your household allergic to animals?
Is anyone in your household afraid of dogs or
cats? YES NO
Have you ever had a dog or cat before?
If yes, what happened to this dog or cat?
Do you have a dog or cat now?
If yes, how many dogs and cats do you currently own?
For each dog or cat you currently own, please answer the
What breed is it?
Is it a male or female?
How old is it?
What sort of temperament does it have, particularly with regard to
Is it spayed or neutered? YES NO
Is it current on all its vaccinations and on heartworm preventative YES NO
If behavior problems arose in your dog, how would you deal with them?
Are you familiar with the animal regulations in your area?
Do you know the requirements for obtaining a
dog/cat license in your town? YES NO
Please list three people (name, address and telephone number) who are
knowledgeable about you and your care of dogs and cats. Please
include your vet as one of them, and two other people in the dog
community (for example, a trainer, a groomer, a rescue person, or
someone who has had dogs or cats all their life and knows you well).
You may include a shelter or rescue person that you once adopted a dog
or cat from. If you do not know a person in the dog community that can
give you a reference, please list two people, who can give you a
character reference, like an employer, a clergyman, or a teacher. List
their names, email addresses or phone numbers, what is their
relationship to dogs/cats, and what is their relationship to you.
Without references we cannot complete your evaluation:
PREFERENCES FOR A DOG OR CAT
Would you consider an older dog/cat (4 years or older)? YES NO
Would you consider a cross?
Would you consider a dog/cat that has a physical problem, i.e., hip
dysplasia, epilepsy, etc. that might be controlled or treated with the
use of drugs, or surgery? YES NO
Would you consider a dog/cat that has an emotional problem, i.e.,
separation anxiety, fear aggression, etc. that might be controlled or
cured with training, behavior modification, or the use of drugs? YES NO
After researching a breed, are there any traits in a breed that you
would prefer to avoid? YES NO
If yes, explain:
Would you consider more than one dog/cat? YES NO
Are you looking for a working/herding dog? YES NO
A dog for a formal sport or competition?
Is there a particular dog or cat on our website that currently
interests you? If so, which one is it?
Are you in a hurry, or are you prepared to wait until the absolute
best match can be made? ___I'm in a hurry. ___I'm willing to wait.
4. YOUR ENVIRONMENT
Do you live in an ___apartment, ___a condo, ___ a mobile home, ___a
single-family house, ___on a farm, ___in military housing?
Do you ___own or ___rent your property?
If you rent, do you have permission from your landlord to have pets on
the property? YES NO
Are there any restrictions as to the number of dogs and /or
combination of dogs and cats that you may have at your residence?
Approximately how large is your property, i.e., square feet, acreage,
Do you have a fenced yard or outdoor kennel? YES NO
What type of fence is it?
How large is the area it encloses?
How high is the fence?
Are you opposed to having someone come to your house to do a home
visit? YES NO
5. YOUR LIFESTYLE WITH REGARD TO A DOG OR CAT
Are you willing to travel a distance to meet a dog or cat?
If so, how far?
Is there someone home during the day most days? YES NO
If not, how many hours will the dog or cat be alone most days?
Will the dog or cat live in the house with the family?
If not, where will it be kept during the day and at night?
When you go away during the day, where will the dog or cat be left?
If you go away for an extended period (overnight or longer), where
will the dog/cat be left?
Will the dog/cat be allowed to run loose at any time?
YES NO NA
Will you have your dog on a run, or trolley, or tied out at any time?
YES NO NA
If yes, please explain when and for how long:
Approximately how much are you willing to spend on vet care for a
dog/cat each year?
What do you see as the normal vet care requirements of a dog/cat?
How do you intend to exercise this dog/cat?
Please add any information about yourself that you think would be
useful in helping us select the right dog or cat for you.
I affirm to the truthfulness of my answers. I
understand that any deception or fabrication of my answers will be
grounds to disallow an adoption of a dog or cat from Charley's Strays,
Inc. I understand that Charley's Strays, Inc. has the right to refuse
any applicant. I also understand that if I do adopt a dog or cat from
Charley's Strays, and for any reason I can not keep him or her, I am required to return
the animal to Charley's Strays.