Ohio River Pet Help and Nurturing Network

Applicant:

* First Name:  * Last Name: 

Co-Applicant:

First Name:  Last Name: 

* Physical Address: 

* City:  * State:   Zip Code: 

Applicant's Occupation:  Co-Applicant's Occupation: 

Applicant's Work Phone:  Co-Applicant's Work Phone: 

* E-Mail: 

* Home Phone:   Cell Phone: 

What's the best way to contact you? 

How did you hear about us? 

Which Dog are you interested in? 

Why do you want a Dog?

Do you live in an:

Do you own or rent your home? Own Rent

If you rent, does your lease/landlord allow you to have a Dog? Yes No

Are there any restrictions on what type of Dog you may have (maximum weight, breed, etc.)? Yes No

If yes what are they? 

Please list people, including yourself, who live in your home:

1.)Name:   Age:   Sex: M F

2.)Name:   Age:   Sex: M F

3.)Name:   Age:   Sex: M F

4.)Name:   Age:   Sex: M F

5.)Name:   Age:   Sex: M F

Are there any other children that visit your home regularly? YesNo

Who will be responsible for the primary care of the pet? 

Do you have a fence? Yes No

If yes, what height? (in feet)

If yes, what type of material is the fence made? Wood Chain Link Other 

If no, are you willing to walk your dog several times a day? Yes No

Will this be an indoor dog? Yes No

If no, where will the dog be kept? 

How long will the dog be alone each day? 

Where will (s)he sleep at night?

Where will (s)he stay when you are away from home? For example;
At work?
On vacation?
In case of emergency?

Please list your current pets:

1.)Name:  Type:  Age:  Spay or Neutered? Yes No

2.)Name:  Type:  Age:  Spay or Neutered? Yes No

3.)Name:  Type:  Age:  Spay or Neutered? Yes No

4.)Name:  Type:  Age:  Spay or Neutered? Yes No

Are these pets kept indoors or outdoors? 

Please list previous pets (use comments section below if necessary):

1.)Name:  Type: 

What happened to him/her? 

2.)Name:  Type: 

What happened to him/her? 

3.)Name:  Type: 

What happened to him/her? 

4.)Name:  Type: 

What happened to him/her? 

If you had a dog before;

What did you like most about him? 

What did you like the least about him? 

Have you ever given up a pet? Yes No

If yes, what were the circumstances? 

Are you willing to train your dog? Yes No

Are you willing to accept a dog that has been abused or neglected? Yes No

Do you anticipate any major changes in the next year (moving, new baby, etc.)? Yes No

If yes, please describe: 

Please provide three references. If you have had pets before one should be your veterinarian. If you rent,
one should be your landlord:

1.)Name  Relationship: 

Phone Number:   Email Address: 

2.)Name  Relationship: 

Phone Number:   Email Address: 

3.)Name  Relationship: 

Phone Number:   Email Address: 

Please type comments here.

I affirm that all the information in this application is true to the best of my knowledge. I agree that ORPHAN may reclaim any dog adopted to me if the information in this application is found to be false or misleading. It is further understood that ORPHAN will solely determine as to whether any of the above statements are in fact false or misleading.

I Agree I Disagree  Date: