Dog Adoption Form Note: You can save your progress and return later by using the link at the bottom of the page.Today's Date* Date Format: MM slash DD slash YYYY Name* First Last Phone*DOB*Email* Physical Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your mailing address different than above?*YesNoMailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country I am interested in a*CatDogName of the pet you are interested in.* Pet Name Would this be your first pet?*YesNoDo you have professional dog training experience?*YesNoOn a scale of 1-10, what is your comfort level with 'reactive' dogs?*Please enter a number from 1 to 10.Are you open to working with one of our trainers?*YesNoDo you have any experience with 'special needs' dogs?*YesNoDo you currently own a pet?*YesNoWhat Kind?*Dog(s)Cat(s)Cat(s) and Dog(s)Bird(s)Reptile(s) or Amphibian(s)OtherHow Many?*Please enter a number from 1 to 10.Name of current animal and breed* Pet Name Breed Approximate Date you got your current pet.* Date Format: MM slash DD slash YYYY Inside or Outside?*InsideOutsideBothSpayed or Neutered?*YesNoCurrent on Vaccinations?*YesNoName of current animal and breed (2nd pet)* Pet Name Breed Approximate Date you got your current pet.* Date Format: MM slash DD slash YYYY Inside or Outside?*InsideOutsideBothSpayed or Neutered?*YesNoCurrent on Vaccinations?*YesNoName of current animal and breed (3rd pet)* Pet Name Breed Approximate Date you got your current pet.* Date Format: MM slash DD slash YYYY Inside or Outside?*InsideOutsideBothSpayed or Neutered?*YesNoCurrent on Vaccinations?*YesNoName of current animal and breed (4th Pet)* Pet Name Breed Approximate Date you got your current pet.* Date Format: MM slash DD slash YYYY Inside or Outside?*InsideOutsideBothSpayed or Neutered?*YesNoCurrent on Vaccinations?*YesNoList any other pets you have (5th or greater)*Please include all previously requested information. Have you owned any animals in the last 10 years that you no longer own?*YesNoHow Many?*Please enter a number from 0 to 10.List names and breeds hereHow long did you have this (these) pet(s)? List date(s) no longer in ownership or passing of pet.*What Happened?*Have you ever surrendered a pet to a shelter/rescue?*YesNoPlease explain why.*Are there any other people in your household other than yourself?*YesNoIf Yes we need you to list name, age and relationship of everyone in the home Including ChildrenHow Many? (Including Children)*Please enter a number from 1 to 11.Name* First Last Age*Relationship*Name* First Last Age*Relationship*Name* First Last Age*Relationship*Name* First Last Age*Relationship*Name* First Last Age*Relationship*Name* First Last Age*Relationship*Name* First Last Age*Relationship*Name* First Last Age*Relationship*Name* First Last Age*Relationship*Name* First Last Age*Relationship*Name* First Last Age*Relationship*Do you live in a House, Apartment, or Condo?*HouseApartmentCondoDo You Rent or Own?*RentOwnName of your landlord First Last Phone number of your landlordIs someone home during the day?*YesNoDo you have a back yard?*YesNoIs your backyard fenced?*Chain LinkPrivacyOtherPartialNoOther? Describe.*Where will the animal stay when no one is home?*Inside, free roamInside, in kennelOutside, back yard free roam (fenced)Outside, in a penOn a runner or cable lineOtherWhere will the dog sleep at night?*InsideOutsideWhat are your thoughts on a dog living indoors?*What are your thoughts on a dog living outdoors?*Will your cat be an 'outdoor' cat? (Allowed to come in and out at request?)*YesNoWhat will their time outside look like? Hours? Free roam?*What are your thoughts on an 'outdoor' cat?*Are your current dog(s) on heart worm prevention?*YesNoVet Information Vet Office Name Vet First Name Vet Last Name Vet Phone NumberName vet records are under First Last Do you consent to give UAAC access to your veterinarian records?*YesNoYou must contact your vet and let them know you give UAAC consent to release vet records to us.* UnderstoodIf you are approved for adoption, are you willing to follow proper introductions if you currently have pets in your home?*YesNoAre you active duty military?*YesNoIs there a chance of deployment?*YesNoIf deployed where will your pets go?*If you should become unable to care for this animal, it must be returned to UAAC. It can not be given away to anyone.* I agreeI am the interested potential adoptive party. I verify that I am at least 18 years of age. My personal identification is consistent with my age and address. I can show proof of housing. I can show proof that I am allowed an animal at my place of residence. Where applicable, all verifiable ESA paperwork will be presented at the time of the animal meet and greet. I understand that any deviation can result in a denied application.* I agreeSignature*Type full name Thank you for choosing adoption. Completion of this application does NOT guarantee adoption. The adoption team will process your application and be in contact with you within 72 hours. Please allow for extended time if a weekend or holiday. Thank you for your patience. CommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.