Adoption Application Step 1 of 5 20% Name of dog applying for Applicant’s name (First, middle, Last Date of Birth MM slash DD slash YYYY Email Home PhoneCell PhoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you adopting through the Pets for Patriots Program? Yes No Personal Reference (Name, address, email, phone)List pets owned past 3 years.Vet Reference Were your pets spayed/neutered? Yes No Why?Were your pets vaccinated? Yes No Why? What happened to your pet?Have you ever given a pet away or surrendered a pet to a shelter? Yes No Why?Number of adults/kids in household and ages?Are any family members allergic to animals? Do you own or rent? Own Rent Are there any pet restrictions? What type of dwelling do you live in? (house, apartment, townhouse) Do you have a fenced in yard? Yes No What type and height? Is everyone in the home agreeable to adopting a dog?Where will the dog be kept during the day and night? How many hours a day will the dog be home alone?Do you plan to tie or chain the dog outside at any time? Yes No Please explain.When you go on vacation, who will care for the dog?Under what circumstances would you surrender a dog?Estimate how much it will cost to provide food, vet care and supplies for a dog for one year.What is your occupation and income range?Any circumstances you would like us to know about?Today’s date. MM slash DD slash YYYY By submitting this form: I agree to the following:I acknowledge that I am at least 18 years of age I acknowledge that I have a state-issued photo ID showing my current address and age I have the knowledge and consent of my landlord or homeowner; if applicable I have the knowledge and consent of all adults living in the household I understand that Humane Society of Calvert County reserves the right to verify any information on this application, including property verification with landlord or homeowner and vaccination history of prior or current pets and vet references: I am able and willing to spend the time and money necessary to provide medical treatment and proper care for a pet I understand that the Humane Society of Calvert County may contact my landlord to verify that the information on this form is correct (if applicant is currently renting) I understand that the Humane Society of Calvert County reserves the right to contact my veterinarian(s) to obtain any information needed to process my application (if applicant has animals at home) I understand that the Humane Society of Calvert County may not be able to adopt the animal of my choice and reserves the right to choose the best qualified home for the animal Please bring a photocopy of a government approved ID when you visit shelter to finalize adoption.