Dog Adoption Application

Clackamas County Dog Services
Animal Adoption On-line Application

First Name

Last Name

Primary Phone

Secondary Phone

Address

City

State
AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT WA WV WI WY

Zip Code

E-mail

Date of Birth
January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Drivers License Number

Drivers License issue date (mm/dd/yyyy

Drivers License expiration date(mm/dd/yyyy)

Are you applying for a particular dog?
Yes No

If yes, please enter the number you see on our web site for the dog

Do you:
Own Rent Other

If other, explain

How long at current address?

If less than 6 months-previous address

Will you be moving soon?
Yes No

Do you live in:
House Apartment Mobile Home Other

Landlord name and phone number (if you don't own)

Do other adults live in this house?
Yes No

Have they approved of this adoption?
Yes No

How many children live in this house?

List the Children's ages who live in this house

Where will this animal be kept during the day?

Where will this animal be kept while you are at work?

Where will this animal be kept in the evening?

Will this animal be:
Indoors Outdoors In/Out

How will you confine your new pet on your property?
Fence Dog Run Trolley Stake in the Ground

Why do you want to adopt a pet?

Do any members of your family have allergies to animals?

Who will be the primary caretaker of this pet?

Who are you adopting this pet for?
Yourself Relative Friend Child

How much do you anticipate spending yearly on a pet you adopt?

If your adopted pet becomes destructive or is not housebroken, what would you do?

Under what circumstances would you not keep this pet?

Please list the pets that you currently own or reside at your home. Include type of animal, male/female, Age, Current of Vaccines, currently licensed and where did you get this pet?

Please list the types and breeds of pets you've owned in the last five years. Include age, how long you owned, and where the animal is now.

Do you have a veterinarian? If yes, please provide your veterinarians name and address.

Return/Exchange Policy
If you are unable to keep this dog, you will be required to return the dog to our shelter.
You may return the dog within 90 days for a refund.
If you return the dog after 90 days, you will be required to pay a $40.00 surrender fee.

1. All dogs adopted from Clackamas County Dog Services are implanted with a microchip.

• Registration of that microchip is a part of your adoption process.
• The cost is $20.00.

2. If you move, what will you do with this animal?

3. Adoption from our shelter requires you to Spay/Neuter this animal, do you have any objections to this procedure
Yes No

If you object, why?

4. Would you be willing to permit a visit by a representative of Clackamas County Dog Services:
Yes No

5. Where did you hear about our adoption program?

Each application requires a $10.00 Non-Refundable deposit applied to your adoption fees when you find your perfect pet within 6 months of date of application. By clicking on "Make Non-Refundable Deposit" below, I certify that the above information is true and accurate to the best of my knowledge and that falsification of information can be cause for denial of my application.  I agree to sign and abide by the adoption agreement.