Dog Application -- Matchmaking Form

Mission Valley Animal Shelter
T: (406) 883-5312 E: mvas@ronan.net
P.O. Box 1644 | 36251 North Reservoir Rd
Polson, Montana 59860


Date:
Dog’s Name Breed Sex Age
Applicant Name:
Street Address: P.O. Box City:
State: Zip Home Phone
Email Address: * Confirmation will be sent to this address


Current Veterinarian Phone #
I wish to adopt because:

Personal References (Please list two non-family -- Names, Phone): 1) 2)
About You and Your Household--Please Check Appropriate Box: Are You:
( ) Working, ( ) Homemaker, ( ) Retired, ( ) Attending school, ( ) other:
Type of Housing: ( ) Home, ( ) Condo, ( ) Apartment, ( ) Mobile Home, ( ) RV ( ) Own,
( ) Rent, ( ) Live with parents, ( ) Rent lot space, ( ) Other:

Landlord's name: Phone:
Others in household (inc. ages of children):

My Experience with dogs: ( ) First time, ( ) Had one or two, ( ) Very experienced

Do you have other pets now? ( ) Yes, ( ) No, If yes: ( ) Cat, ( )
Dog Breed: Where did you get pet?
Length of time you had pet Spayed/Neutered? ( ) Yes ( ) No

If you don't have a pet now, have you ever had a pet before? ( ) Yes, ( ) No
If yes: ( ) Cat, ( ) Dog Breed Spayed/Neutered? ( ) Yes, ( ) No
Length of time you had pet What happened to pet
Have you previously adopted a pet from Mission Valley Animal Shelter? ( ) Yes, ( ) No

Your preferences: Size of dog I'd like: ( ) Small (up to 20 lbs) ( ) Med. (20-50 lbs) ( ) Large (51-100 lbs) ( ) Giant (over 100 lbs).
Prefer: ( ) Male, ( ) Female, ( ) Either
I'd like these personality/temperament traits in my dog: ( ) Quiet, ( ) Mellow, ( ) Affectionate ( ) Lap dog, ( ) Protective, ( ) Vocal, ( ) Herder, ( ) Retriever, ( ) Loves water,
( ) Other:

Training preferences: ( ) None, ( ) Some obedience, ( ) Fully trained, ( ) Housetrained
For exercise I prefer a dog that: ( ) Walks on a leash, ( ) Walks on & off leash, ( ) Run / hike with me
( ) Will exercise itself, ( ) Requires no exercise.

I prefer a dog with an energy level that is: ( ) High, ( ) Moderate, ( ) Low
I presently have: ( ) A fenced yard, ( ) An enclosed kennel, ( ) A stationary tie-up,
( ) Other:
My dog would be (where): during the day, and (where) at night?


I understand the Mission Valley Animal Shelter is under no obligation to adopt the animal described in this Application to me for any reason whatsoever. I further understand that representatives of Mission Valley Animal Shelter will contact the references listed above for suitability for adoption and pet ownership. If I am approved for adoption, I agree to execute an Adoption Agreement and be bound by the terms thereof.

The undersigned releases and holds harmless the Mission Valley Animal Shelter, its employees, agents, officers and directors, from any and all liability which may arise out of any verification of the information contained herein. Mission Valley Animal Shelter agrees that it shall keep information received from such verification confidential.

The undersigned further releases and holds harmless the veterinarian(s) listed on the reverse side hereof, and such veterinarian's clinic, employees, agents, officers and directors, from any and all liability which may arise from information conveyed by such veterinarian or such veterinarian's clinic, employees, agents, officers and directors, to the Mission Valley Animal Shelter as a result of inquiries made in connection with this Adoption Application.


Adopter's Signature Date:


Where did you hear or learn about this pet? ( ) Newspaper Ad ( ) Radio ( ) Poster ( )
Website ( ) Referral ( ) Drop-In ( ) Other:
Are you a member of MV Animal Shelter? ( ) Yes ( ) No
Interested in becoming a member? ( ) Yes ( ) No


Last Update: 4/30