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Dog Adoption Application Form

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 information is required. If you leave any fields blank, it will delay the processing of your application.)

If you would prefer to download this application, click here for a PDF version of the dog adoption application.

In order to be considered as an adopter you must:

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

First Name:

Last Name:


Street Address



State Zip Code


Home Phone

Work Phone

Employed by

Employment Address:

Position Held

Describe in detail the dog you're looking for OR enter the dog's name from Dog Adoption Page:

Why do you want this dog?

Will this be your first dog?

What kind of pet have you had in the past?

If other, list pet:

Which pets do you still have? (age, sex, breed)
Have they been spayed or neutered?
Are vaccinations current?
What happened to pets you no longer have?
Will current pets adjust to new pets in the home?
Was your last dog obedience trained?

Number of adults in your family?
Children's ages?
If allergies to dogs, list whom:

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

Which do you live in? If other, explain. If a house, do you own or rent?

If you rent, may we contact the owner to obtain permission for this animal to live in your home?

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?
What kind of fence?
How high is the fence?
Is there a dog door?

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

Will you keep the vaccinations up to date?
Who is your vet and what is his/her address & phone number?

Please list two personal references (not 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?

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?

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?

Are you willing to take responsibility for this dog for the next ten to fifteen years?

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

If your application is approved, will you be ready to take ownership immediately upon approval?
If not, please explain:

How did you hear of Good Samaritan Pet Center?
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.