Your name *

First Name

Last Name

Current Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Phone (Cell? or Landline?) *

(###)

###

####

Can we text you? *

Yes

No

Additional person (1) living in your household on a regular basis.

First Name

Last Name

Additional person (2) living in your household on a regular basis.

First Name

Last Name

Additional person (3) living in your household on a regular basis.

First Name

Last Name

Additional person (4) living in your household on a regular basis.

First Name

Last Name

Does anyone smoke in your home? *

Yes

No

Is everyone listed above in agreement on this adoption? *

Yes

No

Has anyone living in your home ever been convicted of a criminal offence? HALO reserves the right to conduct background checks. *

Yes

No

Describe the type of your home *

Apartment

Condo

Single-Family House

Townhouse

Trailer

Do you rent or own your home? *

Rent

Own

If renting, does landlord permit a dog?

Yes

No

Do you have a balcony? *

Yes

No

Would you be willing to make adjustments in your home for the safety of the rescued? *

Yes

No

Is your yard fenced?

Yes

No

Do you have a pool? *

Yes

No

What is the name of your landlord?

First Name

Last Name

What is your landlord's phone number?

(###)

###

####

Do you agree that a HALO representative may visit your home? *

Yes

No

Vet Name *

First Name

Last Name

Vet Phone number *

(###)

###

####

Vet Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Has Dog 1 been spayed or neutered?

Spayed

Neutered

No

Has Dog 2 been spayed or neutered?

Spayed

Neutered

No

Has Dog 3 been spayed or neutered?

Spayed

Neutered

No

Has Dog 4 been spayed or neutered?

Spayed

Neutered

No

Do you prefer a male or female? *

Male

Female

No Preference

Where will the dog stay while you are on vacation? *

Friend

Neighbor

Kennel

Relative

Pet Sitter

Other

Do you travel for business? *

Yes

No

Do you currently own any cats? *

Yes

No

If yes, are they indoor or outdoor cats?

Indoor

Outdoor

Do you currently own any pets other than dogs or cats? *

Yes

No

Reference 1 *

First Name

Last Name

Reference 1 Phone *

(###)

###

####

Reference 2 *

First Name

Last Name

Reference 2 Phone *

(###)

###

####

Reference 3 *

First Name

Last Name

Reference 3 Phone *

(###)

###

####

Can you afford emergency medical care for your future pet? *

Yes

No

Do you have, or intend to purchase, pet health insurance? *

Yes

No

Today's date *

MM

DD

YYYY