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 Dog & Puppy Application

Applications take our Adoption Counselor typically 24-72 hours to process. You will be contacted by email or phone call; please check both your email and voicemail for potential messages. Our adoption fees for adults are $100-300 and for puppies are $150-300 (covers full vetting, spay/neuter, microchip, and care of the dog). Adoption fees are payable via cash, credit, or debit; we no longer accept checks. Fees will be paid at the time of adoption and may vary.

Submitting this application does not mean you are committing to a dog, nor does it guarantee you will get that dog.  It is simply a tool we use to help both you and us identify a good potential match for your family and lifestyle. A successful adoption depends on selecting the right dog for your household and a good understanding of the dog's needs and care requirements.  Please help us with this process by answering the following questions fully & completely. THANK YOU!


**Please note that any fields left blank will halt the application reviewing process.

Applicant Information

 Adopter #1  Name: ____________________________________D.O.B ___/___/___

 Adopter #2  Name: ____________________________________D.O.B ___/___/___

Adopter #1 Phone Number ____-____-_____   Email: _________________________

Adopter #2 Phone Number ____-____-_____  Email: _________________________

Adopter #1 Are you currently employed?: ___________________________________

Adopter #2 Are you currently employed?: ___________________________________

Home Address:

Street Name ___________________________ City/State/ZIP _________________

Do you live in (circle):  single family     duplex/twin        apartment      condo       mobile home

Do you (circle):        own       rent       deed/rent to own        reside with relative

If you are not the owner of the home, please provide the homeowner’s information (name and contact information: __________________________________________________

How long have you lived at this residence? ________________________

List any residences you have had in the last 5 years: _____________________________

Household Information

Please list full names and ages of all permanent residents 18 and older: _________________


Ages of all permanent residents 18 and younger: ________________________________


Do you have frequent visitors between the ages of (circle):

0-5 years           6-12 years        13-18 years    None of the above

Does anyone in the household have pet related allergies? __________________________

Who in the household will be the pet’s primary caregiver? __________________________

Pet Ownership

Have you adopted from the Quincy Humane Society in the past? If so, where is the pet now?


Do you currently have any pets?  ___________________

If you currently have pets, please list them. Name, Age, Sex, Breed. ____________________




Are they up to date on vaccinations?     Yes      No       Appointment is scheduled

Are they altered? (spayed/neutered)     Yes      No       Appointment is scheduled

How many pets have you owned in the past 10 years? Where are they now? (Please list breed and ages)


Who is your veterinarian? Clinic Name __________________ Phone: _______________

Home Life

When will you be ready to adopt a dog/puppy? _________________________________

How many hours a day will your dog be alone? Explain. ___________________________

How will you exercise/entertain your dog? ____________________________________

How will you deal with unwanted behaviors such as barking, chewing, destructive behavior,

bathroom accidents, unruly leash behaviors, etc.? _______________________________


Do you plan on (circle):          cropping the ears           docking the tail          debarking           none

Why or why not? ______________________________________________________

How much do you reasonably feel you could afford/ would be willing to spend on your dog per month? (including things like veterinary care, monthly preventions, licensing, ID tags, food, toys, crates, training, supplies) $___________

Do you have a yard? ___________ Fence? __________ What kind? _______________

If you have a vertical fence, what is your fence height? ____________________________

Ideal Pet

Please describe your ideal pet. We will be able to recommend a perfect fit based on what you say

here. ______________________________________________________________


What kind of dog are you looking for? Circle:       Indoor    Outdoor     Indoor/Outdoor

Where will your dog be when you’re home? _________________________________

Where will your dog be when you’re not home? ______________________________

Where will your dog be when you’re asleep? ________________________________

What energy level do you prefer?   Crazy/Adventurous       Medium energy       Couch potato

Why do you want to adopt? Circle:

family pet        companion for child        companion for other dog(s)         companion for other cat(s)

breed with current dog(s)       to train for hunting              therapy dog          assistance to the disabled

guard dog/protection                as a gift for a friend/partner/relative                to train for agility

My adopted dog will (circle):

be indoors        be outdoors        outside during the day/inside at night        roaming the farm

outside in a fenced area       be outside on a lead line/cable in the yard       be walked occasionally

be house trained before adoption         be house trained by me/us        be walked frequently

interacting with adults        interacting with ages 0-10 years        interacting with ages 11-18

be boarded for vacations        stay with family for vacations         go with on vacations

go camping with us         go on boat trips with us         attend agility classes

be given away if it’s no longer working        be given to a shelter if it’s no longer working

Grooming needs (circle):

we prefer a non-shedder              we prefer a low-shedder                    we don’t mind shedding

Have you discussed this adoption with all members of the household?________________

**We will be speaking to all adult residents to confirm everyone is aware of this application process and wants to have a dog added to this family. Please do not submit this application if you are "trying to talk someone into" adopting this dog or think that "once they meet the dog they will change their mind" or "I'm getting this dog as a surprise birthday present for someone". In those circumstances, you are more than welcome to email us to discuss the dog, but we would like all adults in the home to be involved in the email discussion.

What do you feel is a reasonable amount of time for a dog to adjust to a life with you and your

family? ___________________________

How do you plan to integrate this dog into your family? ___________________________

Have you ever turned an animal in to a shelter? ________ Why? ____________________



What would cause you to return a dog? _______________________________________


Please take time to think and be honest when answering the following. What are you absolutely NOT willing to deal with at the time of adoption or at any time during the life of the dog?

housebreaking issues              chewing         counter surfing         fear of men            fear of women

fear  of children        too rough with other pets        too much energy        

growling         biting               too hard to train           needs too much attention       whining/crying

food/toy aggressive with pets      food/toy aggressive with people         separation anxiety        

  blindness          limited sight                deafness        incontinence        

diabetes       special diet        long term medication              heartworm/flea prevention       allergies        

requires too much training         gets stressed/sick in the car        doesn't know how to use stairs

 can’t climb stairs due to age/health                  heart condition                  trimming nails

yeast on coat/in ears     ear mites   fleas  ticks     heartworms       yearly heartworm/lyme testing

We will do anything necessary to help this dog adjust

What would you do if after adoption (or at any time during your dog’s life) your vet diagnosed your dog with an expensive medical condition? ____________________________________________


Do you plan on getting pet insurance?         Yes         No         I will look into it

Are you committed to providing a responsible home for your pet’s entire life? (could be 15 or

more years)                 Yes                 No

Are you willing to sign a legal contract agreeing to pet owner responsibility?         Yes        No

Do you have any additional questions, comments or concerns? Anything else you would like us to know in order to help match a dog with your family? ____________________________


What is the best way to contact you regarding your application?  Phone     or      Email



By my signature, I certify that the above information is complete and correct and that I am at least 18 years of age. I understand that completing this application does not guarantee I will be allowed to adopt a dog and that the application is a tool to help the Quincy Humane Society determine if this dog and my family are a good fit for each other. I understand that all dogs adopted from QHS will be spayed/neutered, heartworm tested, microchipped, and vaccinated prior to adoption. I authorize verification of all statements on this application, including but not limited to prior vet medical history. I understand that QHS has the right to deny my request for adoption. I understand that any misrepresentations may result in my not being approved and may lose the privilege of adopting an animal from QHS. If I am approved to adopt a dog, I agree to pay a non-refundable adoption fee and hand sign an adoption contract at the time of adoption. I understand that this application is the property of the Quincy Humane Society who reserves the right to share this information with other shelters and rescue organizations.

_____ By initialing this line I understand that QHS may conduct a background check and I agree to the above statements.

Adopter #1 Signature & Date                                      Adopter #2 Signature & Date

_________________________                       _____________________________