Current Veterinarian_________________________________ Phone #________________________
I wish to Adopt a Dog Because:______________________________________________________
______________________________________________________________________________
Personal References (Please List Two--Names, Addresses, Phone):
1)_____________________________________________________________________________
2)_____________________________________________________________________________

About You and Your Household--Please Check Appropriate Box (x):
**Are You: (  )Working,   (  )Homemaker,   (  )Retired,    (  )Attending School,    (  )Other: __________
**Employer/Occupation:_________________________________________Bus. Phone:__________
**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:_____________________________________________________________

**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 Have 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 Ever 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 (50-100 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, (  )Housebroken, (  )Fully Trained
**For Exercise I Prefer a Dog that: (  )Walks on a Leash, (  )Walks on & off Leash, (  )Will Run or 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.

Date:_______________              ________________________________________________________
                                                                      (Adopter's Signature)

WHERE DID YOU HEAR OR LEARN ABOUT THIS ANIMAL?
(  )Newspaper Ad     (  )Radio     (  )Poster     (  )Website     (  )Referral     (  )Drop-In     (  )Other:__________________________

ARE YOU A MEMBER OF MISSION VALLEY ANIMAL SHELTER?      (  )Yes     (  )No

WOULD YOU LIKE INFORMATION ON BECOMING A MEMBER?       (  )Yes     (  )No

Application:  (  )Approved     (  )Denied     Date:________________________-
Reason for Denial:_________________________________________________________________________________
DNA List Checked:   (  )