First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Cell Phone*

Are you at least 21 years old?

What's your DOB?*

Housing Status

How long have you lived at this residence?*

If you rent, please list any breed/weight restrictions? We do verify. Please note we do not adopt out bully breed dogs into rentals.

If you rent, please give landlord name & phone # If you rent and do not provide this information you will not be considered.*

Do you have a fenced yard with walls at least 6 ft?

Have you ever rehomed a pet and why?*

Name of dog/cat you are interested in adopting?*

Are there other pets in the home?

Please list any current pets (breeds and ages)

Are current dogs/cats spayed/neutered?

Are current dogs/cats up to date on vaccinations?

Please give current vet name & phone #

Are there any children living in the home?

Please give ages of any children living in the home

Please give a brief descriptions of why this animal would be a good fit for you and breed experience.

Please check that you have read and agree to the following: I agree to indemnify and hold harmless Animal Help Alliance (AHA), its employees, agents, and representatives, from any and all liability arising out of or in consequence of, any injury sustained while handling any animal connected with AHA while volunteering, fostering, or adopting. I further attest that I have truthfully answered all questions in this application to the best of my ability.