Welcome to Good Samaritan Pet Center Adoption Program. The following information is required so that we can assist you in the selection of a new dog. This form and a consultation with a Good Samaritan Representative are designed to help you find the dog most compatible with your lifestyle.
(NOTE: All entries are required.)
 

In order to be considered as an adopter you must:
- Be 21 years of age or older.
- Have identification showing your present address.
- Have the knowledge and consent of your landlord.
- Be able and willing to spend the time and money necessary to provide training, medical treatment
and proper care for a pet.

*Completion of this form does not guarantee adoption of a Good Samaritan Dog
 

Which pets do you still have? (age, sex, breed) 

Have they been spayed or neutered?    Yes No    

Are vaccinations current?  Yes No

What happened to ones you no longer have? 

Will current pets adjusts to new pets in the home? Yes No    

Was last dog obedience trained?  Yes No Don't know

Why do you want this dog?        Number of adults in your family?       Children's ages?   
House Pet Companion Guard Dog Working dog                                                                         

If allergies to dogs, list whom:   

 Number of hours each day dog will be without human companionship?   

Why? 

 Which do you live in?        If other, explain                                                If a house, do you own or rent?
  House Townhome or Condo Apartment Other                                 Own Rent

If you rent, may we contact the owner to obtain permission for this animal to live in your home?  Yes No

If you live in an apartment complex or rent your house, please list the name of the complex as well as the landlord's name and phone number.  For rental properties we check with the landlord to make sure pets are allowed:

Do you have a completely fenced yard?  Yes No    What kind of fence?

How high is the fence?          Is there a dog door?  Yes No

If the new dog/puppy is not housebroken, what training method will be used?

Will you keep the vaccinations up to date?    Yes No      

Who is your vet and what is his/her address & phone number? 

Please list two personal references (not to include relatives or people currently living with you)
Reference #1:  (Name, Address & Phone Number)

Reference # 2:  (Name, Address & Phone Number)

Would you be willing to exercise the dog on a regular basis?  Yes No

Method: 

Where will dog stay during the day? 

Where will dog stay during the night: 

If you drive a pickup truck, would you allow the dog to ride in the back?  No Yes Not Sure

If you go away for a few days, or on a vacation, who will take care of the dog?
 

Are you willing to have a Good Samaritan Pet Center representative come to see where the dog will be living?  Yes No

Are you willing to take responsibility for this dog for the next ten to fifteen years?  Yes No

What provisions will you make for the dog should you become unable to care for it?

How did you hear of Good Samaritan Pet Center?  Word of Mouth Web Search Friend Other Animal Organization Other

If "Other", please define 

Your comments are invited.  Please provide them here: 

Thank you for considering Good Samaritan Pet Center and for choosing a pet which needs a good home!
It is through your kind donations that Good Samaritan Pet Center remains a vital force within the community.

Please insure the above information is correct before submitting.