If you would like to meet one of our dogs, please complete the top half of this form.
Most of our dogs reside in private homes.
Therefore, we need to know you before we send you to those homes to meet dogs.
Your information will be kept private and not sold to marketing firms.

*What is the name of the pet you are interested in?

Where did you first learn about this pet?
 AHeinz57 Website Newspaper Flyers Friend/Family/Co-Worker Petsmart Adoption Day Adopt A Pet

*Full Name:

*Street Address



*Zip Code

Which Iowa County you live in?

*Phone Number


(Inquiries only - Skip to Section 3)


If you would like to be considered for adoption of this dog, please continue.
This is NOT a commitment or contract to adopt. It is for informational use only.
We will contact your landlord and vet, verify home ownership, and possibly do a background check.
Fences are generally required. Exceptions will be made in some instances.

Alternative Phone Number


Names & ages of all household members:

Do you have any other pets at home?
 yes no

If yes, please tell us the type, breed, & ages of each pet:

Do you own or rent your home?
 own rent

If renting, do you have your landlord's permission to adopt this pet?
 yes no N/A

Landlord's Name

Landlord's Phone Number

If you own a Townhouse or Condo, do you have a back yard?
 yes no

Do you have a fenced yard?
 yes no

Do you have plans to move in the future?
 yes no

If yes, what do you plan to do with your pet?

Are your pets spayed or neutered?
 yes no

If no, why not?

Current or Previous Vet's Name:

Current Vet's Phone Number:

What other pets have you had in the past 5 years?

What happened to them? If deceased, please explain.

Will this pet be an inside or outside pet?
 Inside (sleeps in your house) Outside (sleeps outside in dog house or barn, etc.)

If your answer is "outside", please stop here and refer back to our Adoption Process.

Does everyone in your household want to adopt this pet?
 yes no

What are the main reasons for adopting this pet?


Please initial after each statement below. By initialing the statement you are agreeing that you have read it, understand it, and agree with our terms.

*I certify that the information that I have given is true and I authorize investigation of all statements made above. I recognize that any misrepresentation of facts may result in losing the privilege of adopting a pet.

*I understand that AHeinz57 has the right to refuse any request for adoption.

*I give permission to AHeinz57 to share information about me that may be obtained during interviews, reference checks or home visits with other humane organizations.

*Electronic Signature (type name):


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