Application Form Step 1 of 10 10% Personal InformationName* First Last Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*PhoneDate* MM slash DD slash YYYY Occupation Spouse Name First Last First ReferenceName First Last Relationship PhoneSecond ReferenceName First Last Relationship Phone Type of Dwelling* Have you been at your current address longer than one year?* Yes No How Many Years at This AddressAddress* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do You Own or Rent* Rent Own Do you have your landlord's permission to have a dog? Yes No Landlord's Name* First Last Landlord's Phone* Do you have a fenced in yard?* Yes No Fence Height and Type If you do not have a fenced yard, how do you plan to exercise the dog?*Are you familiar with crating?* Yes No What are your thoughts on crates? Persons at HouseholdNameAgeRelationship For each person at your household, please provide the following information. Use the + button to add rows for each person in your home.Dog's Primary Caregiver Has everyone agreed to the adoption? Yes No Cat OwnershipHave you ever owned any cats?* Yes No How many in the last 10 years? Briefly describe what happened to the cats you no longer haveHow many cats do you have now? Are they indoor, outdoor, or both?IndoorOutdoorBothAre they declawed? Yes No Dog OwnershipHave you ever owned any dogs?* Yes No How many in the last 10 years? Briefly explain what happened to the dogs you no longer haveHow many do you own now? Please list each dog you currently ownAgeBreedSpayed/Neutered? Use the + button to add additional rows. Additional PetsDo you have any additional pets?* Yes No Please list all additional pets Use the + button to add more rows. Do you have a vet?* Yes No Name of Vet Vet Phone NumberAddress of Vet 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 Are you familiar with heartworm disease?* Yes No Do you currently practice heart worm prevention? Yes No Which medication? How often? Why do you not practice heartworm prevention? Are you interested in a specific dog of ours?*YesNoWhich one? Personality traits you're seeking in your new dog?Are you willing to do the following?Are you willing to obtain a crate for your dog? Yes No Are you willing to crate train if needed? Yes No Are you willing to house train if needed? Yes No Are you willing to attend obedience classes? Yes No What would you do if your dog bit somebody?The New DogWhere will your new dog spend the day? Where will your new dog spend the night? How many hours will your dog spend alone each day? Who will care for your dog while you are on vacation? Will you allow a representative of Howl at the Moon to visit your home by appointment?*YesNoHow did you hear about Howl at the Moon? Agreement* I agree with the followingYou understand that owning a dog is a commitment for the dog's lifetime and that if you adopt a dog from Howl at the Moon Siberian Rescue Inc., you are affirming that you are both willing and able to make that commitment and that you can responsibly and reliably ensure the safety and welfare of the dogSignatureEmailThis field is for validation purposes and should be left unchanged.