Town of Southbury - Application for Canine Adoption
1
TOWN OF SOUTHBURY
ANIMAL CONTROL
501 Main Street South
Southbury, Connecticut 06488
(203) 262-0613
animalcontrol@southbury-ct.gov
APPLICATION FOR CANINE ADOPTION
The first step in the process of adopting a pet from Southbury Animal Control is to complete this
application. Working with you, we will be able to determine if the adoption is in the pet's best interest,
and the process ensures that you will find a pet well-suited to your lifestyle. Please provide detailed
information for all questions. All information will be kept confidential.
To qualify for adoption, you must:
Be at least 21 years old and have a valid driver's license or state Identification Card stating your
current address.
Have the knowledge and consent of a landlord, if relevant.
Be able and willing to spend the time and money necessary to provide medical treatment,
proper nourishment and care, and training for a pet.
Please note: We reserve the right to refuse adoption to anyone. Please be advised that we will not
adopt to persons who mislead or fail to provide accurate information on this application.
All fields must be filled in, where the question is not applicable please type in N/A.
Typeofdogdesired: Color(s):
Name/descriptionofdogyouareinterestedin:
ABOUTYOUANDYOURFAMILY
YourName:
Address:
City,State,Zip:
Yourdateofbirth: Spouse’sage:
Numberofchildren? Ages:
Telephonenumbers:(home): (work):
Emailaddress:
Areyoupresently:□Employed□Unemployed□Student□Retired□Otherexplain:
Areyouoranymemberofthefamilyallergictopets?□Yes□No.Ifyes,howwouldyoumanagethesituation?
Doyouconsideryourdogapartofthefamily?□Yes□No
Whatdoyouthinkistheestimatedannualcostofowningapet?
Areyouawareofthecurrentlawsinyourtownpertainingtoanimals?□Yes□No.Ifyes,canyouexplainthem?
Howdidyouhearaboutus?
EMAIL APPLICATION
PRINT APPLICATION
Town of Southbury - Application for Canine Adoption
2
ABOUTYOURHOME
Typeofresidence:□House/Own□House/Rent□Apartment□Condo□Townhouse
Howlonghaveyoulivedatthisaddress?
Ifrental,aredogsallowed?□Yes□No□N/A SizeRestrictions?□Yes□No□N/A Max.Size:
Complexname/address:
Manager/Landlord: Phonenumber:
Whattypeofstreetdoyouliveon?□Verybusyroad□Slighttraffic□Countryroad Speedlimit:
Doesyourhomehaveayard?□Yes□No
Doesyouryardhaveafence?□Yes□No Willthegatebelockedwithapadlock?□Yes□No
Whattypeoffencedoyouhave?□ChainLink□Wood□Invisible□Otherspecify:
Doesyouryardhavearun/doghouse?□Yes□No.Ifno,willyouprovideone?
Maywemakeapreadoptionvisittoyourhome?□Yes□No
ABOUTYOURCURRENT/PREVIOUSPETS
Haveyoueverownedapet?□Yes□No Ifyes,pleasecompletethefollowingch artabout yourlast5pets:
TypeofPet YearsOwned Spayed/Neutered Inside/Outside WhereisPetNow?
Yes□No□Inside□Outside
Yes□No□Inside□Outside
Yes□No□Inside□Outside
Yes□No□Inside□Outside
Yes□No□Inside□Outside
Currentorpastvet:
Vet’saddress: Vet’sphone:
Willyouallowustospeakwithyourvettoobtaininformationonthehealthcareofyourpets?□Yes□No
Areallotherpetsinthehousecurrentonvaccinations?
Ifyouhaveacat,doesitgetalongwithdogs?□Yes□No
Areyouexperiencinganydifficultieswithyourcurrentpetsintermsofhealthorbehavior?□Yes□No
Ifyes,pleasedescribe:
YOURPREFERENCES
Whydoyouwantadog?
Haveyouresearchedthebreedyouareinterestedin?
Pleaseexplainthegood&badcharacteristicsofthisbreed:
Whattypeofdogdoyouwishtogiveapermanenthome?□Friendlydog□Highenergydog□Shy/timiddog
□Dogwithmedicalneeds□Dogthatneedstraining□Seniordog
□Physicallychallenged/handicappeddog
Whatstrongpreferencesdoyouhaveinapet:
Whatbehaviorswouldyouhaveahardtimedealingwith?Checkallthatapply:□Shy/Aloof□Digging□Barking
□Stubborn□Nervous□Dominant□Protective□Jumpingonpeople□Chewing□Aggression□Escaping
Whatrolewouldyournewdogplayinyourlife:□Companion/Familypet□Companionforanotherpet
□Guarddog□Breeding□Other:
Ageofdogdesired: Oldestdogconsidered: Approx.weightasanadultdog:
Haveyoueverhousetrainedadog?□Yes□No IfYes,how?
Areyouawarethatadogisalargeandlifelongcommitment?□Yes□No
Town of Southbury - Application for Canine Adoption
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PLANSFORYOURNEWPET
Wherewillthedoglive?□Insideonly□Outsideonly□Mostlyinside□Mostlyoutside□Tiedupoutside
□Runningfree
Wherewillthedogspendnights?□Inside□Outside□Cratedinside□Insidefreeroam
Willyouallowthedogtorunloose?□Yes□No IfYes,where?
Howmanyhoursperdaywillthedogbealone? Wherewillthedogstaywhenleftalone?
Inashelterenvironmentitisdifficulttodetermineifadogishousetrainedwillyoubeabletotolerateafew
accidents?□Yes□No
Whatsolutionwillyoutryifhousebreakingaccidentscontinue afterthefirstweek?□Papertraining□Crate
training□Takeoutmoreoften□Useadogdoor□Seeavet□None□Other(explain)
Howdoyouplanonexercisingyourpet?
Whatisyourpreferredlevelofexercisewiththepet?
Howmanyyearsdoyouplantokeepthedog?
Underwhatcircumstanceswouldyougiveupyourdog?
Haveyouevergivenupadogbefore,ifsowhy?
Doyouagreetospayorneuterthisdogifithasnotbeendonealready?
Areyouwillingtopayforaheartwormtest?
Willyourdogbeonheartwormandflea/tickprevention?□Yes□No
Howdoyoufeelaboutobedienceclasses?
Ifforanyreasoninthefutureyouarenolongerabletokeeptheanimalyouadopt,doyouagreethatyoumust
eitherreturntheanimaltoSouthburyAnimalControl,orfindanewsuitablehomeforthepetandnotifyusofthe
changeinownership?□Yes□No
REFERENCES
PersonalReferences:Pleaselisttworeferences,nonfamilyme mbers,whowemaycall.
Name:
Address: Phone:
Relationtoyou: YearsKnown:
Name:
Address: Phone:
Relationtoyou: YearsKnown:
I certify that the above information is true and I understand that false information may result in
nullification of this application / adoption.
Applicant signature: ____________________________ Date: ___________________
(Signature is required)
Note: A typed name will substitute for a handwritten signature.
PRINT APPLICATION
EMAIL APPLICATION
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