** Your Name:

Co-Applicant:

** Address:

** City:

** State:

AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming

** Zip Code:

** Home Phone:

Work Phone:

Cell Phone:

** E-Mail Address:

** Best time of day to be contacted:

** What Age, Color and Sex of Dog are you interested in?

Are you interested in a specific dog? If so, name?

** Primary Residence:

Own   Rent / Lease

** How long at this Residence:

If you rent / lease, are pets allowed?

Yes  No

Name and phone number of landlord:

May we contact your landlord?:

Yes  No

** Type of Residence:

House  -- Condo / Townhouse -- Apartment  -- Other

** Do you have a fenced yard?:

Yes  No

Approximate size of fenced area:

Fence Height:

Is fence attached to the house?:

Yes  No

Is there shade in the yard?:

Yes  No

Is there shelter in the yard?:

Yes  No

** Do you have a dog door into the house or garage?:

Yes  No

** Will the dog ever be left outside unattended?

Yes  No

If yes, for how long?:

If you have no fence, how do you plan to let the dog go outside?

** Is anyone home during the day?

Yes  No

How many hours would dog be alone?

** Where will the dog be housed at during the day?

** Where will the dog be housed during the night?

** Where will the dog stay when home alone?

** Do you own or have you ever used a crate?

Yes, own and have used     No, but have used one 
Do not own and have not used

** Will the dog be allowed on the furniture?

Yes     No    Only specific pieces

** Will you allow us to conduct a home visit prior to adoption?

Yes     No

What do you do with your pets while on vacation?:

** Why are you interested in adopting a Dalmatian?:

** Are you looking for a Dalmatian as a:

Companion Watchdog Playmate for another Dog
Playmate for a Child Gift for Another Person Other

** Have you ever owned a Dog?:

Yes     No

** Have you ever owned a Dalmatian?:

Yes     No

** Do all adults in the household agree on adopting a Dalmatian?

Yes     No

** Are there children in the household?

Yes     No

Age(s) of child(ren) in the household?:

** Do you have neighbors, family, and / or friends who have children that will visit your home?

Yes     No

Age(s) of child(ren) that will visit your home?:

** Is there anyone in your household with Asthma or Allergies to cats and / or dogs?

Yes     No

** Do you currently have any pets?

Yes     No

Pet 1:

 Type:  Age:
Breed:   Name:
  Sex:             Spayed/Neutered? Yes     No

Pet 2:

 Type:  Age:
Breed:   Name:
  Sex:             Spayed/Neutered? Yes     No

Pet 3:

Type:  Age:
Breed:   Name:
  Sex:             Spayed/Neutered? Yes     No

Pet 4:

Type:  Age:
Breed:   Name:
  Sex:             Spayed/Neutered? Yes     No

Pet 5:

Type:  Age:
Breed:   Name:
  Sex:             Spayed/Neutered? Yes     No

Any behavioral / personality issues with
your current pets?

Yes     No

If Yes, explain.

Where are these
animals kept?

Have you had any other pets in the past five years?

Yes     No

If yes, how many?

What happened to them? If deceased, please provide age and cause of death.

Did you ever have any problems with them?

** Have you ever surrendered a pet to or returned a dog to a shelter?

Yes     No     

If yes, explain

** Have you ever trained in dog obedience or agility?

Yes     No

** Are you willing to?

Yes     No

** Have you ever bred a litter of pups?
OR ever given away
or sold a dog?

Yes     No

If yes, explain

** Adopted pets need time to adjust to their new surroundings. Are you willing to give the new dog at least a one month trial to allow the dog adequate time to adjust?

Yes     No

** What would you consider a reason for not keeping an adopted pet?

If you currently have a dog, what type of dog food do you use?

Wet     Dry      Brand:

How often are the dogs fed?

1 x per day     2 x per day    Continuous / Self Feeder  

Do you use heart worm prevention with your pets?

Yes   No    Don't Know    Type:

Do you use flea prevention with your pets?

Yes    No    Don't Know   Type:

** Do you currently have a Veterinarian?

Yes     No

If yes, name of current Veterinarian:

Address, City, State, & Zip:

Phone Number including area code:

If no current Veterinarian, provide the name and number Veterinarian used in the past.

** May we contact your current / past Veterinarian?

Yes     No

If no Veterinary reference, please provide the Name and Number of 2 personal references other than a relative. These may include neighbors, coworkers, breeders, trainers, etc.

Information or comments you would like to include:

By submitting this application, I agree that:

1. If I am approved for adoption and at any point I find that I can not keep the adopted dog  it will be returned to Carolina Dal Pals immediately.

2. I am authorizing, through submission of this form, the Veterinarian(s) named above to release any information and records concerning past or present care of animals to Carolina Dal Pals. I agree to hold harmless and indemnify said Veterinarian(s) for providing such information.

3. I have not, nor has anyone in my household, ever been charged with any form of animal abuse, neglect, or cruelty.

4. I am 18 years of age and I have read this application in its entirety and have answered each question honestly and to the best of my ability.

** Application Terms: Agree     Don't Agree